Provider Demographics
NPI:1972822336
Name:RUSSELL, SHENIQUE AVIS (LPN)
Entity Type:Individual
Prefix:
First Name:SHENIQUE
Middle Name:AVIS
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 1:31 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14609-6236
Mailing Address - Country:US
Mailing Address - Phone:585-288-0342
Mailing Address - Fax:
Practice Address - Street 1:2180 EMPIRE BLVD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-2029
Practice Address - Country:US
Practice Address - Phone:585-787-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY267200-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse