Provider Demographics
NPI:1235512799
Name:RUSSO, AUDREY (RN)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
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 1:5211 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-6411
Mailing Address - Country:US
Mailing Address - Phone:614-832-4209
Mailing Address - Fax:
Practice Address - Street 1:5211 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-6411
Practice Address - Country:US
Practice Address - Phone:614-832-4209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-02
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95041584163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health