Provider Demographics
NPI:1891118964
Name:RUSSELL, ANNISSA
Entity Type:Individual
Prefix:
First Name:ANNISSA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANNISSA
Other - Middle Name:ELAINE
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:1370 SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1253
Mailing Address - Country:US
Mailing Address - Phone:716-297-0798
Mailing Address - Fax:716-297-0998
Practice Address - Street 1:1370 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1253
Practice Address - Country:US
Practice Address - Phone:716-297-0798
Practice Address - Fax:716-297-0998
Is Sole Proprietor?:No
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY650966163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY650966OtherNYS LICENSE