Provider Demographics
NPI:1124072038
Name:RUSSO, LAURA LYNN (DC)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:LYNN
Last Name:RUSSO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:525 PEACHTREE INDUSTRIAL BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4071
Mailing Address - Country:US
Mailing Address - Phone:770-831-7556
Mailing Address - Fax:770-831-7928
Practice Address - Street 1:525 PEACHTREE INDUSTRIAL BLVD STE D
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4071
Practice Address - Country:US
Practice Address - Phone:770-831-7556
Practice Address - Fax:770-831-7928
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008176111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor