Healthcare Provider Details

I. General information

NPI: 1306024963
Provider Name (Legal Business Name): MRS. NANCY LYNN RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 FERN RD
CALVERTON NY
11933-2617
US

IV. Provider business mailing address

6 FERN RD
CALVERTON NY
11933-2617
US

V. Phone/Fax

Practice location:
  • Phone: 631-591-1456
  • Fax:
Mailing address:
  • Phone: 631-591-1456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number485078
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: