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General NPI Number Information
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NPI Number | 1659405835
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Entity Type | Individual
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Provider Name | LISA RUSSAK NP
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Gender | Female
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Dates
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Enumeration Date | 03/16/2007
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Last Update Date | 08/01/2013
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Provider Practice Location Address
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Address Line | 121 DEKALB AVE
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City | BROOKLYN
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State | NY
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Zip | 11201-5425
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Country | US
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Telephone | 718-250-6534
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Fax |
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Provider Business Mailing Address
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Address Line | 249 BEACH 141ST ST
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City | BELLE HARBOR
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State | NY
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Zip | 11694-1229
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Country | US
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Telephone | 917-848-2463
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | F303001
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License Number State | NY
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