Provider Demographics
NPI:1033499736
Name:RUSS, MARCELLA KAZIER
Entity Type:Individual
Prefix:MISS
First Name:MARCELLA
Middle Name:KAZIER
Last Name:RUSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 MAPLE ST FL 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-1313
Mailing Address - Country:US
Mailing Address - Phone:718-213-1659
Mailing Address - Fax:
Practice Address - Street 1:11727 221ST ST
Practice Address - Street 2:
Practice Address - City:CAMBRIA HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11411-1612
Practice Address - Country:US
Practice Address - Phone:718-213-1659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1211-5739246RP1900X
NY308356-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy