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General NPI Number Information
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NPI Number | 1922809672
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Entity Type | Individual
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Provider Name | KORAH ANN RUSSELL
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Gender | Female
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Dates
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Enumeration Date | 03/20/2025
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Last Update Date | 03/20/2025
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Provider Practice Location Address
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Address Line | 236 BURTS RD
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City | KIRKWOOD
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State | NY
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Zip | 13795-1731
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Country | US
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Telephone | 877-426-3307
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Fax |
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Provider Business Mailing Address
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Address Line | 145 BARKER RD APT A
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City | WHITNEY POINT
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State | NY
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Zip | 13862-2608
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Country | US
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Telephone | 607-206-3195
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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 | 2080P0006X
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Taxonomy Name | Developmental - Behavioral Pediatrics Physician
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License Number | 3182214
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License Number State | NY
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