Provider Demographics
NPI:1790784932
Name:RUSSO, KATHLEEN (ARNP)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3492
Mailing Address - Street 2:
Mailing Address - City:PLACIDA
Mailing Address - State:FL
Mailing Address - Zip Code:33946-3492
Mailing Address - Country:US
Mailing Address - Phone:941-698-0703
Mailing Address - Fax:
Practice Address - Street 1:700 MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223-3964
Practice Address - Country:US
Practice Address - Phone:941-475-6571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2918432363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019998700Medicaid
FLU3315ZMedicare PIN
FL019998700Medicaid