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General NPI Number Information
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NPI Number | 1700541711
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Entity Type | Individual
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Provider Name | CONNIE JO RUSSO LMT
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Gender | Female
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Dates
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Enumeration Date | 11/04/2021
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Last Update Date | 11/13/2024
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Provider Practice Location Address
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Address Line | 34921 US 19 N STE 250
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City | PALM HARBOR
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State | FL
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Zip | 34684-1969
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Country | US
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Telephone | 727-992-1696
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1252
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City | TARPON SPRINGS
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State | FL
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Zip | 34688-1252
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Country | US
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Telephone | 727-992-1696
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 25841
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License Number State | FL
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