Provider Demographics
NPI:1851530919
Name:RUSSO, MARGUERITE M (CRNP)
Entity Type:Individual
Prefix:MS
First Name:MARGUERITE
Middle Name:M
Last Name:RUSSO
Suffix:
Gender:F
Credentials:CRNP
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 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-0838
Mailing Address - Fax:410-328-0509
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-0838
Practice Address - Fax:410-328-0509
Is Sole Proprietor?:No
Enumeration Date:2009-02-13
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR142683363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD044553300Medicaid
MDS062-0574OtherCAREFIRST BC/BS
MDR142683OtherSTATE LICENSE
MDS062-0574OtherCAREFIRST BC/BS
MD211505Medicare Oscar/Certification
MD227793Y1PMedicare PIN