Provider Demographics
NPI:1558548453
Name:RUSSO, TAMI LYNN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:TAMI
Middle Name:LYNN
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 MALVERN CURV
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-8738
Mailing Address - Country:US
Mailing Address - Phone:716-807-9738
Mailing Address - Fax:
Practice Address - Street 1:221 HIGHLAND PKWY
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14223-1407
Practice Address - Country:US
Practice Address - Phone:716-873-6999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008343174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY008343OtherL.M.T.