Healthcare Provider Details

I. General information

NPI: 1124312053
Provider Name (Legal Business Name): TERESA MARIE RUSSELL MS, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2011
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 1ST AVE STE 8R
NEW YORK NY
10016-6402
US

IV. Provider business mailing address

530 1ST AVE STE 8R
NEW YORK NY
10016-6402
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-5035
  • Fax: 646-501-0493
Mailing address:
  • Phone: 212-263-5035
  • Fax: 646-501-0493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number336636
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00333100
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF336636-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: