Provider Demographics
NPI:1356572747
Name:RUSSO, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 WEST ST APT 3
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-6532
Mailing Address - Country:US
Mailing Address - Phone:978-886-5441
Mailing Address - Fax:
Practice Address - Street 1:38 MONTVALE AVE STE 330
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-2450
Practice Address - Country:US
Practice Address - Phone:978-886-5441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2452225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist