Provider Demographics
NPI:1073922076
Name:RUSS, MONIQUE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:RUSS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 OAKBRIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-5945
Mailing Address - Country:US
Mailing Address - Phone:913-549-3884
Mailing Address - Fax:913-273-3373
Practice Address - Street 1:1201 OAKBRIDGE PKWY
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-5945
Practice Address - Country:US
Practice Address - Phone:913-549-3884
Practice Address - Fax:913-273-3373
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11029934363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily