Provider Demographics
NPI:1770673469
Name:RUSSOFRANCO, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:RUSSOFRANCO
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 1:611 N MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:HO HO KUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07423-1668
Mailing Address - Country:US
Mailing Address - Phone:201-447-1112
Mailing Address - Fax:201-447-1280
Practice Address - Street 1:611 N MAPLE AVE
Practice Address - Street 2:
Practice Address - City:HO HO KUS
Practice Address - State:NJ
Practice Address - Zip Code:07423-1668
Practice Address - Country:US
Practice Address - Phone:201-447-1112
Practice Address - Fax:201-447-1280
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01184500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJNL7012OtherHEALTHNET
NJ0224219OtherORTHONET/AETNA