Provider Demographics
NPI:1093976003
Name:RUSSO, TAMMY J (NPP)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:J
Last Name:RUSSO
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:J
Other - Last Name:LEBLANC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NPP
Mailing Address - Street 1:2141 EASTERN PKWY
Mailing Address - Street 2:
Mailing Address - City:NISKAYUNA
Mailing Address - State:NY
Mailing Address - Zip Code:12309-6343
Mailing Address - Country:US
Mailing Address - Phone:518-982-1274
Mailing Address - Fax:518-982-1277
Practice Address - Street 1:2141 EASTERN PKWY
Practice Address - Street 2:
Practice Address - City:NISKAYUNA
Practice Address - State:NY
Practice Address - Zip Code:12309-6343
Practice Address - Country:US
Practice Address - Phone:518-518-8172
Practice Address - Fax:518-982-1277
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401129-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health