Provider Demographics
NPI:1609539121
Name:RUSSELL, MAUREEN ELIZABETH (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:MAUREEN
Middle Name:ELIZABETH
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 THE MALL ST
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-1436
Mailing Address - Country:US
Mailing Address - Phone:518-248-8180
Mailing Address - Fax:
Practice Address - Street 1:427 GUY PARK AVE
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-1064
Practice Address - Country:US
Practice Address - Phone:518-770-7518
Practice Address - Fax:518-770-7570
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF348723363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily