Provider Demographics
NPI:1124736988
Name:RUSSELL, MICHAELA
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
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 1:35 SAYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:CT
Mailing Address - Zip Code:06426-1490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 SAYBROOK RD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1490
Practice Address - Country:US
Practice Address - Phone:860-767-0168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11311363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner