Provider Demographics
NPI:1255042826
Name:RUSS, IVORY
Entity type:Individual
Prefix:
First Name:IVORY
Middle Name:
Last Name:RUSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SUMMER BREEZE WAY APT 1106
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-1804
Mailing Address - Country:US
Mailing Address - Phone:912-342-9829
Mailing Address - Fax:
Practice Address - Street 1:300 SUMMER BREEZE WAY APT 1106
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-1804
Practice Address - Country:US
Practice Address - Phone:912-342-9829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31101007251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health