Basic Information
| Provider Information | |||||||||
| NPI: | 1366795551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEVY | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | E. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5496 E TAFT RD | ||||||||
| Address2: | |||||||||
| City: | NORTH SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132123784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155526700 | ||||||||
| FaxNumber: | 3155526701 | ||||||||
| Practice Location | |||||||||
| Address1: | 5496 E TAFT RD | ||||||||
| Address2: | |||||||||
| City: | NORTH SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132123784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155526700 | ||||||||
| FaxNumber: | 3155526701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2012 | ||||||||
| LastUpdateDate: | 02/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 337402 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 03519028 | 05 | NY | MEDICAID |