Provider Demographics
NPI:1841040300
Name:RUSS, KAREN LYNN
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:LYNN
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 1:2700 CLEARLAKE RD
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-5716
Mailing Address - Country:US
Mailing Address - Phone:321-631-0373
Mailing Address - Fax:
Practice Address - Street 1:2700 CLEARLAKE RD
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-5716
Practice Address - Country:US
Practice Address - Phone:321-631-0373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician