Provider Demographics
NPI:1114763455
Name:RUSSELL, EMILY BROOKE
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:BROOKE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 LOUEY RD
Mailing Address - Street 2:
Mailing Address - City:DICKINSON CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:12930-1723
Mailing Address - Country:US
Mailing Address - Phone:518-651-7491
Mailing Address - Fax:
Practice Address - Street 1:146 LOUEY RD
Practice Address - Street 2:
Practice Address - City:DICKINSON CENTER
Practice Address - State:NY
Practice Address - Zip Code:12930-1723
Practice Address - Country:US
Practice Address - Phone:518-651-7491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-05
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF311786363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health