Provider Demographics
NPI:1427262385
Name:RUSSO, TAMMY (NP)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 PINE ST
Mailing Address - Street 2:
Mailing Address - City:RIVERVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-6229
Mailing Address - Country:US
Mailing Address - Phone:201-750-6873
Mailing Address - Fax:
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:5 MAIN ROOM # 5637
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1914
Practice Address - Country:US
Practice Address - Phone:201-996-4838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN10094200363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health