Provider Demographics
NPI:1073933917
Name:RUSSELL, JODI-ANN
Entity Type:Individual
Prefix:MS
First Name:JODI-ANN
Middle Name:
Last Name:RUSSELL
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 1:17 BUFFALO AVE
Mailing Address - Street 2:APT 58
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751
Mailing Address - Country:US
Mailing Address - Phone:631-482-6473
Mailing Address - Fax:
Practice Address - Street 1:508 AIRPORT EXECUTIVE BOULEVARD
Practice Address - Street 2:
Practice Address - City:NANUET
Practice Address - State:NY
Practice Address - Zip Code:10958
Practice Address - Country:US
Practice Address - Phone:845-425-2655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-18
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY299412164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse