Provider Demographics
NPI:1124771506
Name:RUSSO, KELSEY (APN)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 MEETING HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:SEA GIRT
Mailing Address - State:NJ
Mailing Address - Zip Code:08750-2207
Mailing Address - Country:US
Mailing Address - Phone:908-692-4391
Mailing Address - Fax:
Practice Address - Street 1:1945 NJ-33
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753
Practice Address - Country:US
Practice Address - Phone:732-775-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01099000363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health