Provider Demographics
NPI:1437394624
Name:RUSS, DOROTHY ROSE (RN)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:ROSE
Last Name:RUSS
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:W11353 MAIN STREET RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-8970
Mailing Address - Country:US
Mailing Address - Phone:608-617-7778
Mailing Address - Fax:866-747-7459
Practice Address - Street 1:W11353 MAIN STREET RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-8970
Practice Address - Country:US
Practice Address - Phone:608-617-7778
Practice Address - Fax:866-747-7459
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI84360-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse