Provider Demographics
NPI:1982983011
Name:RUSSOMANNO, CHRISTINA (NP)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:RUSSOMANNO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:
Other - Last Name:BALDWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:161 FORT WASHINGTON AVE
Mailing Address - Street 2:GARDEN LEVEL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032
Mailing Address - Country:US
Mailing Address - Phone:646-317-5077
Mailing Address - Fax:212-305-8112
Practice Address - Street 1:161 FORT WASHINGTON AVE
Practice Address - Street 2:GARDEN LEVEL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:646-317-5077
Practice Address - Fax:212-305-8112
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-07
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305852363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY08580930Medicaid