Provider Demographics
NPI:1497113427
Name:RUSSELL, MARJORIE (NPP)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:36 BRITISH AMERICAN BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-1410
Mailing Address - Country:US
Mailing Address - Phone:518-389-6606
Mailing Address - Fax:518-389-6605
Practice Address - Street 1:36 BRITISH AMERICAN BLVD
Practice Address - Street 2:STE 102
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1410
Practice Address - Country:US
Practice Address - Phone:518-389-6606
Practice Address - Fax:518-389-6605
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-04
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY40401959363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health