Provider Demographics
NPI:1750881678
Name:RUSSO, REBEKAH NICOLE (LVN)
Entity type:Individual
Prefix:MISS
First Name:REBEKAH
Middle Name:NICOLE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7129 STATE HIGHWAY 79 N
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76305-2766
Mailing Address - Country:US
Mailing Address - Phone:940-923-1312
Mailing Address - Fax:
Practice Address - Street 1:7129 STATE HIGHWAY 79 N
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76305-2766
Practice Address - Country:US
Practice Address - Phone:940-923-1312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX338907164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse