Provider Demographics
NPI:1255477196
Name:RUSSO, SUSAN T (APN)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:T
Last Name:RUSSO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:T
Other - Last Name:LEVY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:185 SUTTLE ST
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-8276
Mailing Address - Country:US
Mailing Address - Phone:970-335-2232
Mailing Address - Fax:970-335-2440
Practice Address - Street 1:1970 E 3RD AVE
Practice Address - Street 2:UNIT 1
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5056
Practice Address - Country:US
Practice Address - Phone:970-335-2288
Practice Address - Fax:970-335-2280
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0100009-CNS363LC1500X, 363L00000X, 363LP0808X
IL309003290363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner