Provider Demographics
NPI:1063158798
Name:ROSS-GLASS, LETICIA MARIE
Entity type:Individual
Prefix:MRS
First Name:LETICIA
Middle Name:MARIE
Last Name:ROSS-GLASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3540 SUMMER AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38122-3600
Mailing Address - Country:US
Mailing Address - Phone:901-623-6220
Mailing Address - Fax:
Practice Address - Street 1:3540 SUMMER AVE STE 320
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38122-3600
Practice Address - Country:US
Practice Address - Phone:901-623-6220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN882060119Medicaid