Provider Demographics
NPI:1366795551
Name:RUSSELL, NICOLE E (NP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:E
Other - Last Name:LEVY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5496 E TAFT RD
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-3784
Mailing Address - Country:US
Mailing Address - Phone:315-552-6700
Mailing Address - Fax:315-552-6701
Practice Address - Street 1:5496 E TAFT RD
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-3784
Practice Address - Country:US
Practice Address - Phone:315-552-6700
Practice Address - Fax:315-552-6701
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY337402363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03519028Medicaid