Basic Information
| Provider Information | |||||||||
| NPI: | 1801109350 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROSS | ||||||||
| FirstName: | TAMMY | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 MAIN ST S | ||||||||
| Address2: | |||||||||
| City: | MC KEE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404477089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596267700 | ||||||||
| FaxNumber: | 8596267890 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 STACY LANE RD | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403367356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067230665 | ||||||||
| FaxNumber: | 6067230680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2010 | ||||||||
| LastUpdateDate: | 02/11/2014 | ||||||||
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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 | 363LF0000X | 3006534 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100134760 | 05 | KY | MEDICAID | P400039548 | 01 | KY | MEDICARE PTAN | OTHER |