MEDICARE: MRS. NANCY GRACE RUSSO WILSON ARNP

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	363LF0000X	Family Nurse Practitioner	ARNP9228952	FL
2	363LF0000X	Family Nurse Practitioner	NYS330384	NY

General Provider Information

NPI Number	:	1639106651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NANCY GRACE RUSSO WILSON ARNP

Provider Business Mailing Address
First Line	:	5132 OCEAN BLVD
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34242-1637
Country	:	US
Telephone Number	:	941-349-1411
Fax Number	:	941-346-0885

Provider Business Practice Location Address
First Line	:	5132 OCEAN BLVD
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34242-1637
Country	:	US
Telephone Number	:	941-349-1411
Fax Number	:	941-346-0885

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

Provider Enumeration Date	:	06/26/2006
Last Update Date	:	09/20/2007

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