Provider Demographics
NPI:1710131321
Name:RUSSOMANNO, LINDA ANNE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:ANNE
Last Name:RUSSOMANNO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 CHRIS GAUPP DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-4492
Mailing Address - Country:US
Mailing Address - Phone:609-910-0270
Mailing Address - Fax:609-910-3350
Practice Address - Street 1:408 CHRIS GAUPP DR STE 100
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-4492
Practice Address - Country:US
Practice Address - Phone:609-910-0270
Practice Address - Fax:609-910-3350
Is Sole Proprietor?:No
Enumeration Date:2008-11-10
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR11522300163W00000X
NJ26NJ01124700363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse