Provider Demographics
NPI:1982935763
Name:NISLY, ROSS ELLIS
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:ELLIS
Last Name:NISLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34569 NEWELL ST
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-6864
Mailing Address - Country:US
Mailing Address - Phone:909-268-6900
Mailing Address - Fax:
Practice Address - Street 1:2080 S E ST
Practice Address - Street 2:#100
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2706
Practice Address - Country:US
Practice Address - Phone:909-388-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550198163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1124100383Medicaid