MEDICARE: PHYLLIS JUNE RUSSO MSN, ARNP, GCNS-BC

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	363LG0600X	Gerontology Nurse Practitioner	ARNP 2128402	FL
2	364SG0600X	Gerontology Clinical Nurse Specialist	0134457-18	CT

General Provider Information

NPI Number	:	1932108586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHYLLIS JUNE RUSSO MSN, ARNP, GCNS-BC

Provider Business Mailing Address
First Line	:	2675 CREEK LN
Second Line	:	# 202
City	:	NAPLES
State	:	FL
Zip	:	34119-7992
Country	:	US
Telephone Number	:	239-860-7587
Fax Number	:

Provider Business Practice Location Address
First Line	:	3368 WOODS EDGE CIR
Second Line	:	SUITE 104
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-3437
Country	:	US
Telephone Number	:	239-495-5315
Fax Number	:	239-596-1709

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

Provider Enumeration Date	:	07/16/2005
Last Update Date	:	12/09/2009

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