Provider Demographics
NPI:1871614826
Name:RUSSO, LUANN (CNM)
Entity type:Individual
Prefix:
First Name:LUANN
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 KINGS HWY E
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-4867
Mailing Address - Country:US
Mailing Address - Phone:203-367-2273
Mailing Address - Fax:203-382-0856
Practice Address - Street 1:501 KINGS HWY E
Practice Address - Street 2:SUITE 202
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-4867
Practice Address - Country:US
Practice Address - Phone:203-367-2273
Practice Address - Fax:203-382-0856
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT000137367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004209632Medicaid