Provider Demographics
NPI:1912424094
Name:ROSS, CICELY A (NP)
Entity Type:Individual
Prefix:
First Name:CICELY
Middle Name:A
Last Name:ROSS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:CICELY
Other - Middle Name:A
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP-C
Mailing Address - Street 1:600 CELEBRATE LIFE PKWY
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-8001
Mailing Address - Country:US
Mailing Address - Phone:770-400-6296
Mailing Address - Fax:
Practice Address - Street 1:1133 EAGLES LANDING PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5085
Practice Address - Country:US
Practice Address - Phone:678-604-1053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN177619363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA$$$$$$$$$Medicaid
GA$$$$$$$$$OtherPALLITAVE CARE MEDICINE