Provider Demographics
NPI:1578777629
Name:RUSSO, DALLAS GALE (RN)
Entity Type:Individual
Prefix:MS
First Name:DALLAS
Middle Name:GALE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:DALLAS
Other - Middle Name:GALE
Other - Last Name:BATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:14277 ROAD 28
Mailing Address - Street 2:P.O. BOX 1288
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93638-5715
Mailing Address - Country:US
Mailing Address - Phone:559-673-3508
Mailing Address - Fax:559-661-2818
Practice Address - Street 1:14277 ROAD 28
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638-5715
Practice Address - Country:US
Practice Address - Phone:559-673-3508
Practice Address - Fax:559-661-2818
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA461890163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health