Provider Demographics
NPI:1568723880
Name:RUSSI, LYNN
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:RUSSI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 KLEIN RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-1708
Mailing Address - Country:US
Mailing Address - Phone:716-688-6743
Mailing Address - Fax:
Practice Address - Street 1:106 KLEIN RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-1708
Practice Address - Country:US
Practice Address - Phone:716-688-6743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY572418051174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist