Individual
MARY ROSS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
10825 OLD HIGHWAY 64, BOLIVAR, TN 38008-3599
(731) 658-5291
(731) 658-6536
Mailing address
10825 OLD HIGHWAY 64, PO BOX 670, BOLIVAR, TN 38008-3599
(731) 658-5291
(731) 658-6536
Taxonomy
Speciality
Code
Description
License number
State
163WC1500X
Community Health Registered Nurse
Primary
0000095307
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
626001445
STATE OF TN
TN
Enumeration date
07/15/2015
Last updated
07/15/2015
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