MEDICARE: PAMELA SULLIVAN RUSS LP, 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	103TC0700X	Clinical Psychologist	LP3039	MN

General Provider Information

NPI Number	:	1760663819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAMELA SULLIVAN RUSS LP, RN

Provider Business Mailing Address
First Line	:	8420 DELANEY COURT
Second Line	:
City	:	INVER GROVE HEIGHTS
State	:	MN
Zip	:	55076
Country	:	US
Telephone Number	:	651-455-3162
Fax Number	:

Provider Business Practice Location Address
First Line	:	8420 DELANEY CT
Second Line	:
City	:	INVER GROVE HEIGHTS
State	:	MN
Zip	:	55076-3425
Country	:	US
Telephone Number	:	651-455-3162
Fax Number	:

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

Provider Enumeration Date	:	11/16/2007
Last Update Date	:	03/11/2008

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