Provider Demographics
NPI:1932108586
Name:RUSSO, PHYLLIS JUNE (MSN, ARNP, GCNS-BC)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:JUNE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MSN, ARNP, GCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 CREEK LN
Mailing Address - Street 2:# 202
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-7992
Mailing Address - Country:US
Mailing Address - Phone:239-860-7587
Mailing Address - Fax:
Practice Address - Street 1:3368 WOODS EDGE CIR
Practice Address - Street 2:SUITE 104
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-3437
Practice Address - Country:US
Practice Address - Phone:239-495-5315
Practice Address - Fax:239-596-1709
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-16
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 2128402363LG0600X
CT0134457-18364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY5060Medicare ID - Type Unspecified
FLPO5266Medicare UPIN