Provider Demographics
NPI:1104549187
Name:RUSSO, SHELLY (APRN)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1215 JACARANDA BLVD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-4520
Mailing Address - Country:US
Mailing Address - Phone:941-451-8282
Mailing Address - Fax:877-652-3059
Practice Address - Street 1:1215 JACARANDA BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-4520
Practice Address - Country:US
Practice Address - Phone:941-451-8282
Practice Address - Fax:877-652-3059
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FL11021994363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health