Provider Demographics
NPI:1750652830
Name:RUSSELL, JODY ANN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JODY
Middle Name:ANN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 BREAKEY AVE
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701-2530
Mailing Address - Country:US
Mailing Address - Phone:845-796-3058
Mailing Address - Fax:845-796-5035
Practice Address - Street 1:45 BREAKEY AVE
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-2530
Practice Address - Country:US
Practice Address - Phone:845-796-3058
Practice Address - Fax:845-796-5035
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY264167164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse