Provider Demographics
NPI:1093119216
Name:RUSSO, REBECCA LOUISE (DNP, FNP-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LOUISE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:DNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-0040
Mailing Address - Country:US
Mailing Address - Phone:508-909-7799
Mailing Address - Fax:508-764-2432
Practice Address - Street 1:10 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARLTON
Practice Address - State:MA
Practice Address - Zip Code:01507-1590
Practice Address - Country:US
Practice Address - Phone:508-248-1770
Practice Address - Fax:508-248-1769
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5951363L00000X, 363LF0000X
CT88008163WU0100X
MARN252020363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WU0100XNursing Service ProvidersRegistered NurseUrology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily