Provider Demographics
NPI:1891217022
Name:RUSSO, LISA C (APRN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:RUSSO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:C
Other - Last Name:MAGISTRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:38 RICHILL RD
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-2604
Mailing Address - Country:US
Mailing Address - Phone:203-871-9975
Mailing Address - Fax:
Practice Address - Street 1:1 CELLINI PL STE 102
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-1666
Practice Address - Country:US
Practice Address - Phone:203-932-6481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7045363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily