Provider Demographics
NPI:1144712118
Name:ROSS, CARRIE ANNE
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANNE
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 1:324 LYON ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5607
Mailing Address - Country:US
Mailing Address - Phone:616-451-2039
Mailing Address - Fax:616-451-3590
Practice Address - Street 1:324 LYON ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5607
Practice Address - Country:US
Practice Address - Phone:616-451-2039
Practice Address - Fax:616-451-3590
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist