Provider Demographics
NPI:1104136902
Name:RUSSO, DOREEN RUTH (RN)
Entity type:Individual
Prefix:MRS
First Name:DOREEN
Middle Name:RUTH
Last Name:RUSSO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:DOREEN
Other - Middle Name:RUTH
Other - Last Name:HABITZREUTHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:346 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-1804
Mailing Address - Country:US
Mailing Address - Phone:716-856-7500
Mailing Address - Fax:716-961-4419
Practice Address - Street 1:346 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-1804
Practice Address - Country:US
Practice Address - Phone:716-856-7500
Practice Address - Fax:716-961-4419
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3395501163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice