Provider Demographics
NPI:1619305620
Name:RUSSEK, ANGELA L (NP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:RUSSEK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 HEATH STAGE TER
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE FALLS
Mailing Address - State:MA
Mailing Address - Zip Code:01370-9436
Mailing Address - Country:US
Mailing Address - Phone:413-625-9717
Mailing Address - Fax:413-625-9329
Practice Address - Street 1:25 HEATH STAGE TER
Practice Address - Street 2:
Practice Address - City:SHELBURNE FALLS
Practice Address - State:MA
Practice Address - Zip Code:01370-9436
Practice Address - Country:US
Practice Address - Phone:413-625-9717
Practice Address - Fax:413-625-9329
Is Sole Proprietor?:No
Enumeration Date:2013-10-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2272735363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health