MEDICARE: AUDREY RUSSO R.N.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WH0200X	Home Health Registered Nurse	95041584	CA

General Provider Information

NPI Number	:	1235512799
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUDREY RUSSO R.N.

Provider Business Mailing Address
First Line	:	5211 LOCUST AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90805-6411
Country	:	US
Telephone Number	:	614-832-4209
Fax Number	:

Provider Business Practice Location Address
First Line	:	5211 LOCUST AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90805-6411
Country	:	US
Telephone Number	:	614-832-4209
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2015
Last Update Date	:	02/08/2016

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