Basic Information
| Provider Information | |||||||||
| NPI: | 1982935763 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NISLY | ||||||||
| FirstName: | ROSS | ||||||||
| MiddleName: | ELLIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34569 NEWELL ST | ||||||||
| Address2: | |||||||||
| City: | YUCAIPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923996864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092686900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2080 S E ST | ||||||||
| Address2: | #100 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924082706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093889191 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2010 | ||||||||
| LastUpdateDate: | 01/19/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 550198 | CA | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 1124100383 | 05 | CA | MEDICAID |