Provider Demographics
NPI:1114071222
Name:RUSSELL, LUCY G
Entity Type:Individual
Prefix:
First Name:LUCY
Middle Name:G
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 1:1748 HACKAMORE RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-1226
Mailing Address - Country:US
Mailing Address - Phone:307-632-0284
Mailing Address - Fax:307-778-3944
Practice Address - Street 1:1748 HACKAMORE RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-1226
Practice Address - Country:US
Practice Address - Phone:307-632-0284
Practice Address - Fax:307-778-3944
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator