Provider Demographics
NPI:1477918902
Name:RUSSELL, JENNIFER CATHLEEN (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CATHLEEN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:NY
Mailing Address - Zip Code:14092-1903
Mailing Address - Country:US
Mailing Address - Phone:716-297-4800
Mailing Address - Fax:
Practice Address - Street 1:5300 MILITARY RD
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-1903
Practice Address - Country:US
Practice Address - Phone:716-297-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307524363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner