Basic Information
| Provider Information | |||||||||
| NPI: | 1578500682 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSO | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 191 | ||||||||
| Address2: | |||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197230191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026514000 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 ROCKLAND ROAD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198033607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026514200 | ||||||||
| FaxNumber: | 3026515365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 07/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | RN336781L | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 367500000X | RN336781L | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | L10036317 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367H00000X | L10036317 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367500000X | L60A00549 | DE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.