Provider Demographics
NPI:1972707396
Name:RUSSO, NADINE ANN
Entity Type:Individual
Prefix:MRS
First Name:NADINE
Middle Name:ANN
Last Name:RUSSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 HARVEST LN
Mailing Address - Street 2:
Mailing Address - City:PLANTSVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06479-1041
Mailing Address - Country:US
Mailing Address - Phone:860-621-5078
Mailing Address - Fax:
Practice Address - Street 1:91 NORTHWEST DR
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-1534
Practice Address - Country:US
Practice Address - Phone:860-793-3809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization