Provider Demographics
NPI:1578500682
Name:RUSSO, KIMBERLY A (CRNA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:RUSSO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 191
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19723-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-4000
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:1600 ROCKLAND ROAD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3607
Practice Address - Country:US
Practice Address - Phone:302-651-4200
Practice Address - Fax:302-651-5365
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN336781L208000000X, 367500000X
DEL10036317367500000X, 367H00000X
DEL60A00549367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant