Basic Information
| Provider Information | |||||||||
| NPI: | 1093119216 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSO | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | DNP, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40 | ||||||||
| Address2: | |||||||||
| City: | SOUTHBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015500040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089097799 | ||||||||
| FaxNumber: | 5087642432 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CHARLTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015071590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5082481770 | ||||||||
| FaxNumber: | 5082481769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2014 | ||||||||
| LastUpdateDate: | 10/15/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5951 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | RN252020 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 5951 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.