Healthcare Provider Details

I. General information

NPI: 1114468048
Provider Name (Legal Business Name): JESSICA LUCARELLI-RUSSELL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 06/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 MAIN ST
BRIDGEPORT CT
06606-4201
US

IV. Provider business mailing address

2800 MAIN ST
BRIDGEPORT CT
06606-4201
US

V. Phone/Fax

Practice location:
  • Phone: 203-576-5708
  • Fax:
Mailing address:
  • Phone: 203-509-3732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6968
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: