Provider Demographics
NPI:1043423064
Name:NELSON RUSSOM, LYNN ANN (RNC,MSN,CRNP)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:ANN
Last Name:NELSON RUSSOM
Suffix:
Gender:F
Credentials:RNC,MSN,CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7921 WESTVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-2810
Mailing Address - Country:US
Mailing Address - Phone:610-449-0711
Mailing Address - Fax:
Practice Address - Street 1:WIDENER UNIVERSITY STUDENT HEALTH SERVICES
Practice Address - Street 2:ONE UNIVERSITY PLACE
Practice Address - City:CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19013
Practice Address - Country:US
Practice Address - Phone:610-499-1183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAUP000904C363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health