1043423064 NPI number — LYNN ANN NELSON RUSSOM RNC,MSN,CRNP

Table of content: LYNN ANN NELSON RUSSOM RNC,MSN,CRNP (NPI 1043423064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043423064 NPI number — LYNN ANN NELSON RUSSOM RNC,MSN,CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON RUSSOM
Provider First Name:
LYNN
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RNC,MSN,CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043423064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7921 WESTVIEW AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UPPER DARBY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19082-2810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-449-0711
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WIDENER UNIVERSITY STUDENT HEALTH SERVICES
Provider Second Line Business Practice Location Address:
ONE UNIVERSITY PLACE
Provider Business Practice Location Address City Name:
CHESTER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-499-1183
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  UP000904C , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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