Provider Demographics
NPI:1871640490
Name:RUSSO, DIANE KAY (DC)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:KAY
Last Name:RUSSO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 TERRELL MILL RD SE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-6049
Mailing Address - Country:US
Mailing Address - Phone:770-984-2813
Mailing Address - Fax:770-984-9416
Practice Address - Street 1:1475 TERRELL MILL RD SE
Practice Address - Street 2:SUITE 108
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-6049
Practice Address - Country:US
Practice Address - Phone:770-984-2813
Practice Address - Fax:770-984-9416
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR005940111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor