Provider Demographics
NPI:1750494225
Name:RUSSELL, ROSEMARY A (NP)
Entity Type:Individual
Prefix:MS
First Name:ROSEMARY
Middle Name:A
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 VILLAGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509
Mailing Address - Country:US
Mailing Address - Phone:845-279-4450
Mailing Address - Fax:
Practice Address - Street 1:1071 STONELEIGH AVE
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512
Practice Address - Country:US
Practice Address - Phone:845-225-3591
Practice Address - Fax:845-225-3553
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF4008901363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMR1185455OtherDEA
Q66302Medicare UPIN
1599G1Medicare ID - Type Unspecified