Provider Demographics
NPI:1134006331
Name:RUSSOTTO, NELLIE R
Entity type:Individual
Prefix:
First Name:NELLIE
Middle Name:R
Last Name:RUSSOTTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NELLIE
Other - Middle Name:ROSALIE
Other - Last Name:D'ALBORA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1224 MILL ST STE 224
Mailing Address - Street 2:
Mailing Address - City:EAST BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06023-1159
Mailing Address - Country:US
Mailing Address - Phone:657-566-2588
Mailing Address - Fax:
Practice Address - Street 1:1224 MILL ST STE 224
Practice Address - Street 2:
Practice Address - City:EAST BERLIN
Practice Address - State:CT
Practice Address - Zip Code:06023-1159
Practice Address - Country:US
Practice Address - Phone:657-566-2588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-19
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT25482899246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty