Provider Demographics
NPI:1427263383
Name:LARUSSO, ELLEN L (APRN)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:L
Last Name:LARUSSO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5220 BELFORT RD STE 103
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6017
Mailing Address - Country:US
Mailing Address - Phone:904-446-3424
Mailing Address - Fax:904-443-3369
Practice Address - Street 1:301 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5167
Practice Address - Country:US
Practice Address - Phone:386-231-3615
Practice Address - Fax:386-231-3614
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF335300-1363LF0000X
NC5009587363LF0000X
390200000X
FL9428863363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program