Provider Demographics
NPI:1982045878
Name:NELSON, ALEXANDRA RUSSOMANO (PT)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:RUSSOMANO
Last Name:NELSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4610 CENTER BLVD APT 717
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11109-5851
Mailing Address - Country:US
Mailing Address - Phone:973-725-1944
Mailing Address - Fax:
Practice Address - Street 1:333 E 38TH ST FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-2772
Practice Address - Country:US
Practice Address - Phone:646-501-7077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist