Provider Demographics
NPI:1962703587
Name:RUSSO, MARY R (RN)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:R
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 1:603 WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5635
Mailing Address - Country:US
Mailing Address - Phone:607-277-3415
Mailing Address - Fax:607-277-3415
Practice Address - Street 1:603 WILLOW AVE
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3555
Practice Address - Country:US
Practice Address - Phone:607-277-3415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-12
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY399994-1163W00000X, 364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Yes163W00000XNursing Service ProvidersRegistered Nurse