Provider Demographics
NPI:1740911726
Name:ROSS, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17 MARKET ST APT 5E
Mailing Address - Street 2:
Mailing Address - City:ELLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12428-2154
Mailing Address - Country:US
Mailing Address - Phone:845-293-7124
Mailing Address - Fax:
Practice Address - Street 1:751 BRIGGS HWY
Practice Address - Street 2:
Practice Address - City:ELLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12428-5501
Practice Address - Country:US
Practice Address - Phone:845-647-8006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY275797164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse