Provider Demographics
NPI:1376663849
Name:RUSSO, DAWN MARIE (NP)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:MARIE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 PARKER DR
Mailing Address - Street 2:
Mailing Address - City:ISLAMORADA
Mailing Address - State:FL
Mailing Address - Zip Code:33036-3835
Mailing Address - Country:US
Mailing Address - Phone:516-368-4989
Mailing Address - Fax:
Practice Address - Street 1:3301 OVERSEAS HWY
Practice Address - Street 2:
Practice Address - City:MARATHON
Practice Address - State:FL
Practice Address - Zip Code:33050-2398
Practice Address - Country:US
Practice Address - Phone:516-368-4989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY413287163WM0705X
NYF332165363LF0000X
FL11014872363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1502G1Medicare ID - Type Unspecified
NYQ64507Medicare UPIN