Provider Demographics
NPI:1609164532
Name:RUSSELL, MARK L (APRN)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 LASALLE RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2322
Mailing Address - Country:US
Mailing Address - Phone:860-906-1289
Mailing Address - Fax:860-906-1269
Practice Address - Street 1:125 LASALLE RD
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2322
Practice Address - Country:US
Practice Address - Phone:860-906-1289
Practice Address - Fax:860-906-1269
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT077986363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT077986OtherLICENSE