Provider Demographics
NPI:1245796325
Name:RUSSO, NICKI LEE (RN)
Entity Type:Individual
Prefix:
First Name:NICKI
Middle Name:LEE
Last Name:RUSSO
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 1:1374 N GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:KITTANNING
Mailing Address - State:PA
Mailing Address - Zip Code:16201-1052
Mailing Address - Country:US
Mailing Address - Phone:724-954-5203
Mailing Address - Fax:
Practice Address - Street 1:11 HILLTOP PLZ
Practice Address - Street 2:
Practice Address - City:KITTANNING
Practice Address - State:PA
Practice Address - Zip Code:16201-8905
Practice Address - Country:US
Practice Address - Phone:724-545-8420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN642111163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse