Healthcare Provider Details

I. General information

NPI: 1447315064
Provider Name (Legal Business Name): PAULA ROSALIE RUSSO APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25965 S. NORMANDIE
HARBOR CITY CA
90710-3416
US

IV. Provider business mailing address

1730 FREEPORT TER
SAN PEDRO CA
90732-4045
US

V. Phone/Fax

Practice location:
  • Phone: 310-517-2124
  • Fax: 310-517-4103
Mailing address:
  • Phone: 310-548-4547
  • Fax: 310-517-4103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374T00000X
TaxonomyReligious Nonmedical Nursing Personnel
License Number335202
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: