Provider Demographics
NPI:1811014269
Name:RUSSO, VINCE R (LPN)
Entity Type:Individual
Prefix:MR
First Name:VINCE
Middle Name:R
Last Name:RUSSO
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4305 GYPSY LN
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-1165
Mailing Address - Country:US
Mailing Address - Phone:484-902-8223
Mailing Address - Fax:267-354-6899
Practice Address - Street 1:4305 GYPSY LN
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-1165
Practice Address - Country:US
Practice Address - Phone:484-902-8223
Practice Address - Fax:267-354-6899
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN262002164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse