MEDICARE: IVA CAROL RUSSELL RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN 3379892	FL

General Provider Information

NPI Number	:	1598734014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVA CAROL RUSSELL RN

Provider Business Mailing Address
First Line	:	2917 SUTTON OAKS CT
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33566-9609
Country	:	US
Telephone Number	:	813-707-8244
Fax Number	:	813-903-4812

Provider Business Practice Location Address
First Line	:	2917 SUTTON OAKS CT
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33566-9609
Country	:	US
Telephone Number	:	813-707-8244
Fax Number	:	813-903-4812

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	07/08/2007

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