Provider Demographics
NPI:1962493866
Name:RUSSO, SUSAN LEE (CNM)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 FIERY RUN RD
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:VA
Mailing Address - Zip Code:22642-1831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4001 FAIR RIDGE DR
Practice Address - Street 2:SUITE 303
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2917
Practice Address - Country:US
Practice Address - Phone:703-359-4842
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024094866367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife