Provider Demographics
NPI:1447795810
Name:RUSSO, ANGELA (AUD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 WETZEL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4188
Mailing Address - Country:US
Mailing Address - Phone:719-526-4095
Mailing Address - Fax:
Practice Address - Street 1:6301 WETZEL AVE
Practice Address - Street 2:BLDG 1525
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4188
Practice Address - Country:US
Practice Address - Phone:719-526-4095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT006492231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist