Provider Demographics
NPI:1063445518
Name:RUSSO, MARIA L (RN)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:L
Last Name:RUSSO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 RODERICK ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MORGAN CITY
Mailing Address - State:LA
Mailing Address - Zip Code:70380-2247
Mailing Address - Country:US
Mailing Address - Phone:985-380-2455
Mailing Address - Fax:985-380-2470
Practice Address - Street 1:512 RODERICK ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-2247
Practice Address - Country:US
Practice Address - Phone:985-380-2455
Practice Address - Fax:985-380-2470
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN081292163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9701OtherANCB