Provider Demographics
NPI:1528743101
Name:ROSS, BRIDGETTE SHANTA
Entity type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:SHANTA
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRIDGETTE
Other - Middle Name:SHANTA
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12021 WILMINGTON AVE BLDG 18
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-3019
Mailing Address - Country:US
Mailing Address - Phone:424-454-5568
Mailing Address - Fax:
Practice Address - Street 1:12021 WILMINGTON AVE BLDG 18
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3019
Practice Address - Country:US
Practice Address - Phone:424-454-5568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker