Provider Demographics
NPI:1386461333
Name:RUSSO, DIANA ELIZABETH
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:ELIZABETH
Last Name:RUSSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5445 NW 122ND DR
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-3631
Mailing Address - Country:US
Mailing Address - Phone:954-257-1746
Mailing Address - Fax:
Practice Address - Street 1:5445 NW 122ND DR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33076-3631
Practice Address - Country:US
Practice Address - Phone:954-257-1746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN1035381363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily