Provider Demographics
NPI:1811775117
Name:RUSS, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:RUSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:RIDGWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:64 MAPLE ST EXT
Mailing Address - Street 2:UNIT A
Mailing Address - City:KENT
Mailing Address - State:CT
Mailing Address - Zip Code:06757
Mailing Address - Country:US
Mailing Address - Phone:860-419-5925
Mailing Address - Fax:
Practice Address - Street 1:64 MAPLE ST EXT
Practice Address - Street 2:UNIT A
Practice Address - City:KENT
Practice Address - State:CT
Practice Address - Zip Code:06757
Practice Address - Country:US
Practice Address - Phone:860-419-5925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12374363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily