Provider Demographics
NPI:1932443371
Name:RUSSO, ANNEMARIE CHRISTINE (LM)
Entity Type:Individual
Prefix:
First Name:ANNEMARIE
Middle Name:CHRISTINE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 514
Mailing Address - Street 2:
Mailing Address - City:STINSON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:94970-0514
Mailing Address - Country:US
Mailing Address - Phone:650-279-6429
Mailing Address - Fax:
Practice Address - Street 1:14 CANYON RD
Practice Address - Street 2:
Practice Address - City:BOLINAS
Practice Address - State:CA
Practice Address - Zip Code:94924
Practice Address - Country:US
Practice Address - Phone:650-279-6429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALM343176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife