Provider Demographics
NPI:1073936100
Name:RUSSELL, LATRECE
Entity Type:Individual
Prefix:
First Name:LATRECE
Middle Name:
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 1:4734 S PRAIRIE AVE
Mailing Address - Street 2:UNIT1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-1206
Mailing Address - Country:US
Mailing Address - Phone:708-252-1958
Mailing Address - Fax:
Practice Address - Street 1:4734 S PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-1206
Practice Address - Country:US
Practice Address - Phone:708-252-1958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other