Provider Demographics
NPI:1114326006
Name:RUSSIE, LANYNE JOELLE
Entity Type:Individual
Prefix:
First Name:LANYNE
Middle Name:JOELLE
Last Name:RUSSIE
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 1:7824 PAPER FLOWER CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-7328
Mailing Address - Country:US
Mailing Address - Phone:702-259-0908
Mailing Address - Fax:
Practice Address - Street 1:7824 PAPER FLOWER CT
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-7328
Practice Address - Country:US
Practice Address - Phone:702-259-0908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1730214651OtherEAGLE QUEST OF NEVADA