Provider Demographics
NPI:1881376143
Name:STACY R ROSS APRN LLC
Entity type:Organization
Organization Name:STACY R ROSS APRN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:859-325-3059
Mailing Address - Street 1:3455 COUNTRYSIDE BLVD UNIT 12
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-1306
Mailing Address - Country:US
Mailing Address - Phone:859-325-3059
Mailing Address - Fax:
Practice Address - Street 1:3455 COUNTRYSIDE BLVD UNIT 12
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-1306
Practice Address - Country:US
Practice Address - Phone:859-325-3059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-04
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)