Provider Demographics
NPI:1588952527
Name:RUSSO, NICOLE THERESE (RN)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:THERESE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 KELSEY RD
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-3329
Mailing Address - Country:US
Mailing Address - Phone:774-270-4938
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:774-270-4938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2260824163W00000X
IDN-39148163W00000X
FLRN9292245163W00000X
WARN60083206163W00000X
OR200540747RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse