Provider Demographics
NPI:1124312053
Name:RUSSELL, TERESA MARIE (MS, FNP)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:
Credentials:MS, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 1ST AVE STE 8R
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6402
Mailing Address - Country:US
Mailing Address - Phone:212-263-5035
Mailing Address - Fax:646-501-0493
Practice Address - Street 1:530 1ST AVE STE 8R
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-5035
Practice Address - Fax:646-501-0493
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336636363LF0000X
NJ26NJ00333100363LF0000X
NYF336636-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily