Provider Demographics
NPI:1215570981
Name:RUSSELL LEWIS, MARY MAGDALENE (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MAGDALENE
Last Name:RUSSELL LEWIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 S OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-5512
Mailing Address - Country:US
Mailing Address - Phone:516-965-0709
Mailing Address - Fax:
Practice Address - Street 1:396 S OCEAN AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-5512
Practice Address - Country:US
Practice Address - Phone:516-965-0709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY421341163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY421341Medicaid