Basic Information
| Provider Information | |||||||||
| NPI: | 1578891065 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | LAKESIA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FLUKER | ||||||||
| OtherFirstName: | LAKESIA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6285 BARFIELD RD NE | ||||||||
| Address2: | STE 250 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303284335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043031224 | ||||||||
| FaxNumber: | 4043031325 | ||||||||
| Practice Location | |||||||||
| Address1: | 4488 N SHALLOWFORD RD | ||||||||
| Address2: | STE 210 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303386413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707300451 | ||||||||
| FaxNumber: | 7703942764 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2009 | ||||||||
| LastUpdateDate: | 11/23/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN149127 | GA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.