Healthcare Provider Details

I. General information

NPI: 1255477196
Provider Name (Legal Business Name): SUSAN T RUSSO APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN T LEVY APN

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 01/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 E 3RD AVE UNIT 1
DURANGO CO
81301-5056
US

IV. Provider business mailing address

185 SUTTLE ST
DURANGO CO
81303-8276
US

V. Phone/Fax

Practice location:
  • Phone: 970-335-2288
  • Fax: 970-335-2280
Mailing address:
  • Phone: 970-335-2232
  • Fax: 970-335-2440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN.0100009-CNS
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License NumberAPN.0100009-CNS
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number309003290
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.0100009-CNS
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: