Provider Demographics
NPI:1174155485
Name:ROSS, MARIA SUSENA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:SUSENA
Last Name:ROSS
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 1:1500 MEREDITH AVE
Mailing Address - Street 2:
Mailing Address - City:GUSTINE
Mailing Address - State:CA
Mailing Address - Zip Code:95322-1701
Mailing Address - Country:US
Mailing Address - Phone:209-600-2102
Mailing Address - Fax:
Practice Address - Street 1:1500 MEREDITH AVE
Practice Address - Street 2:
Practice Address - City:GUSTINE
Practice Address - State:CA
Practice Address - Zip Code:95322-1701
Practice Address - Country:US
Practice Address - Phone:209-600-2102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95096064163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WS0200XNursing Service ProvidersRegistered NurseSchoolGroup - Single Specialty