Provider Demographics
NPI:1548767783
Name:LORUSSO, CHYNNA JANAE
Entity Type:Individual
Prefix:
First Name:CHYNNA
Middle Name:JANAE
Last Name:LORUSSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5321 SHAW AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-3023
Mailing Address - Country:US
Mailing Address - Phone:314-393-4205
Mailing Address - Fax:
Practice Address - Street 1:5321 SHAW AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-3023
Practice Address - Country:US
Practice Address - Phone:314-393-4205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO119457367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered