Provider Demographics
NPI:1093449282
Name:RUSSO, ASHLEY RENEE
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:RENEE
Last Name:RUSSO
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 1:3784 N TILLOTSON AVE APT 114
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-1784
Mailing Address - Country:US
Mailing Address - Phone:574-327-5099
Mailing Address - Fax:
Practice Address - Street 1:1615 W RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303
Practice Address - Country:US
Practice Address - Phone:765-285-5178
Practice Address - Fax:765-285-8762
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program