Provider Demographics
NPI:1124299631
Name:RUSSO, KATHRYN D (NP)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:D
Last Name:RUSSO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3904
Mailing Address - Country:US
Mailing Address - Phone:617-421-1194
Mailing Address - Fax:617-421-1187
Practice Address - Street 1:147 MILK ST
Practice Address - Street 2:PROVIDER ENROLLMENT DEPT. - 9TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-4806
Practice Address - Country:US
Practice Address - Phone:617-559-8374
Practice Address - Fax:617-421-3487
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA239289363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily