Provider Demographics
NPI:1346386489
Name:RUSSELL, PETER WARD (LPN HOME CARE)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:WARD
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LPN HOME CARE
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 19
Mailing Address - Street 2:CHAMPLAIN RD
Mailing Address - City:STILLWATER
Mailing Address - State:NY
Mailing Address - Zip Code:12170-0019
Mailing Address - Country:US
Mailing Address - Phone:518-664-6361
Mailing Address - Fax:
Practice Address - Street 1:12 PETRA LANE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205
Practice Address - Country:US
Practice Address - Phone:518-452-0445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167571164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse