Provider Demographics
NPI:1639662349
Name:RUSSO, REBECCA ANN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:RUSSO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANN
Other - Last Name:FOBAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:229 SUMMIT ST STE 4
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-1645
Mailing Address - Country:US
Mailing Address - Phone:585-815-6710
Mailing Address - Fax:585-815-6711
Practice Address - Street 1:229 SUMMIT ST STE 4
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-1645
Practice Address - Country:US
Practice Address - Phone:585-815-6710
Practice Address - Fax:585-815-6711
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704289501363L00000X
NY345861363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner