Healthcare Provider Details

I. General information

NPI: 1164991949
Provider Name (Legal Business Name): LAUREN BRYANT RUSSO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2018
Last Update Date: 11/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3781 S HIGH ST
COLUMBUS OH
43207-4011
US

IV. Provider business mailing address

2780 AIRPORT DR STE 100
COLUMBUS OH
43219-2289
US

V. Phone/Fax

Practice location:
  • Phone: 614-645-3163
  • Fax: 614-645-5893
Mailing address:
  • Phone: 614-859-1906
  • Fax: 614-645-5517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number409369
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number023857
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: