Provider Demographics
NPI:1114337003
Name:RUSSELL, TAVISHA NAKIA (CNA)
Entity Type:Individual
Prefix:
First Name:TAVISHA
Middle Name:NAKIA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9916 24TH AVENUE CT S
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-7743
Mailing Address - Country:US
Mailing Address - Phone:253-217-1763
Mailing Address - Fax:
Practice Address - Street 1:9600 VETERANS DRIVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98493
Practice Address - Country:US
Practice Address - Phone:253-582-8440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANC60272176376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
WANC60272176OtherNAC