Basic Information
| Provider Information | |||||||||
| NPI: | 1669936258 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | MARINA | ||||||||
| MiddleName: | B | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 E DIXIE AVE | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347486350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524313940 | ||||||||
| FaxNumber: | 3524313173 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 SKYLINE DR STE 1 | ||||||||
| Address2: | |||||||||
| City: | LADY LAKE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321594592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524313940 | ||||||||
| FaxNumber: | 3524313173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2019 | ||||||||
| LastUpdateDate: | 01/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0810X | APRN11001032 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Child & Family |
ID Information
| ID | Type | State | Issuer | Description | APRN11001032 | 01 | FL | LICENSE | OTHER |