Provider Demographics
NPI:1265178883
Name:RUSSELL, DONNA (RN)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23136 WILLIAMS RD
Mailing Address - Street 2:
Mailing Address - City:LA FARGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13656-3122
Mailing Address - Country:US
Mailing Address - Phone:315-783-3208
Mailing Address - Fax:
Practice Address - Street 1:23136 WILLIAMS RD
Practice Address - Street 2:
Practice Address - City:LA FARGEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13656-3122
Practice Address - Country:US
Practice Address - Phone:315-783-3208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY617536-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse