Individual
MARK L RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
APRN
Contact information
Practice address
125 LASALLE RD, WEST HARTFORD, CT 06107-2322
(860) 906-1289
(860) 906-1269
Mailing address
125 LASALLE RD, WEST HARTFORD, CT 06107-2322
(860) 906-1289
(860) 906-1269
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
077986
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
077986
LICENSE
CT
Enumeration date
07/12/2011
Last updated
06/04/2015
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