Basic Information
| Provider Information | |||||||||
| NPI: | 1982914065 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 N WILLOW AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385012335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315288899 | ||||||||
| FaxNumber: | 9315207655 | ||||||||
| Practice Location | |||||||||
| Address1: | 402 E GORE AVE | ||||||||
| Address2: | |||||||||
| City: | GAINESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385629367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312686899 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2010 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APN15173 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 3013214 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100169440 | 05 | KY | MEDICAID | 1522232 | 05 | TN | MEDICAID | 4338108 | 01 | TN | BCTN | OTHER |