Healthcare Provider Details

I. General information

NPI: 1346162039
Provider Name (Legal Business Name): KATHARINE LO RUSSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 RIDGEFIELD DR
SHOREHAM NY
11786-2034
US

IV. Provider business mailing address

66 RIDGEFIELD DR
SHOREHAM NY
11786-2034
US

V. Phone/Fax

Practice location:
  • Phone: 631-655-2156
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number3188650
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: