Provider Demographics
NPI:1568883973
Name:RUSSO, ELIZABETH (ANP-BC)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-0553
Mailing Address - Fax:
Practice Address - Street 1:71 KENDALL ST
Practice Address - Street 2:
Practice Address - City:CLIFTON SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:14432
Practice Address - Country:US
Practice Address - Phone:315-462-0447
Practice Address - Fax:315-462-3891
Is Sole Proprietor?:No
Enumeration Date:2014-01-02
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303057-1363LA2200X
NY499435-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse