Provider Demographics
NPI:1043090079
Name:RUSSELL, SHELLY R
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:R
Last Name:RUSSELL
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 1:14617 99TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223-6288
Mailing Address - Country:US
Mailing Address - Phone:425-870-8208
Mailing Address - Fax:
Practice Address - Street 1:9528 STATE AVE STE B
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-2279
Practice Address - Country:US
Practice Address - Phone:360-659-6554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61484804225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist