Provider Demographics
NPI:1316546708
Name:RUSSO, ASHLEY MICHELLE (NP-C)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MICHELLE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1446 N KEYSTONE ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-1008
Mailing Address - Country:US
Mailing Address - Phone:727-480-0180
Mailing Address - Fax:
Practice Address - Street 1:440 E HUNTINGTON DR STE 200
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-3775
Practice Address - Country:US
Practice Address - Phone:626-254-2293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-18
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015708363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner