Provider Demographics
NPI:1689858730
Name:RUSSO, NICOLETTE ANN (RN)
Entity Type:Individual
Prefix:MS
First Name:NICOLETTE
Middle Name:ANN
Last Name:RUSSO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 VESTER AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-1303
Mailing Address - Country:US
Mailing Address - Phone:937-342-0689
Mailing Address - Fax:
Practice Address - Street 1:1231 VESTER AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-1303
Practice Address - Country:US
Practice Address - Phone:937-342-0689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN 153812163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2208953Medicaid