Provider Demographics
NPI:1023534351
Name:RUSSO, CHERYL (LPN)
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 AVENUE G
Mailing Address - Street 2:
Mailing Address - City:MATAMORAS
Mailing Address - State:PA
Mailing Address - Zip Code:18336-1212
Mailing Address - Country:US
Mailing Address - Phone:845-313-8570
Mailing Address - Fax:
Practice Address - Street 1:20 OLD TURNPIKE RD
Practice Address - Street 2:
Practice Address - City:NANUET
Practice Address - State:NY
Practice Address - Zip Code:10954-2532
Practice Address - Country:US
Practice Address - Phone:845-624-0260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY329522-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse