Healthcare Provider Details

I. General information

NPI: 1255042826
Provider Name (Legal Business Name): IVORY RUSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2022
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SUMMER BREEZE WAY APT 1106
ST AUGUSTINE FL
32086-1804
US

IV. Provider business mailing address

300 SUMMER BREEZE WAY APT 1106
ST AUGUSTINE FL
32086-1804
US

V. Phone/Fax

Practice location:
  • Phone: 912-342-9829
  • Fax:
Mailing address:
  • Phone: 912-342-9829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number31101007
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: