Provider Demographics
NPI:1720496532
Name:RUSSO, DYNELLA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:DYNELLA
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 ARMOUR PL
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-1204
Mailing Address - Country:US
Mailing Address - Phone:201-314-1902
Mailing Address - Fax:
Practice Address - Street 1:125 W COPELAND DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-3280
Practice Address - Country:US
Practice Address - Phone:321-841-7090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR16740400390200000X
NY593722390200000X
NJ26NJ00739600363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program