Provider Demographics
NPI:1164578506
Name:RUSSO, PATRICIA J (BC-HIS)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:J
Last Name:RUSSO
Suffix:
Gender:F
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 N PALAFOX ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502-4838
Mailing Address - Country:US
Mailing Address - Phone:850-438-4092
Mailing Address - Fax:850-438-4095
Practice Address - Street 1:115 N PALAFOX ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-4838
Practice Address - Country:US
Practice Address - Phone:850-438-4092
Practice Address - Fax:850-438-4095
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS 1379237700000X, 247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL085155800Medicaid
FL161297600OtherACS
FLT 0094OtherBCBS
FLJ0195OtherUAW
FL085429800Medicaid