Provider Demographics
NPI:1952634818
Name:RUSSO, HOLLY RENEE' (RN)
Entity Type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:RENEE'
Last Name:RUSSO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 TANNER ST
Mailing Address - Street 2:
Mailing Address - City:STONEWALL
Mailing Address - State:LA
Mailing Address - Zip Code:71078-4455
Mailing Address - Country:US
Mailing Address - Phone:318-925-2335
Mailing Address - Fax:
Practice Address - Street 1:158 TANNER ST
Practice Address - Street 2:
Practice Address - City:STONEWALL
Practice Address - State:LA
Practice Address - Zip Code:71078-4455
Practice Address - Country:US
Practice Address - Phone:318-925-2335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN125144163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse