Provider Demographics
NPI:1174291975
Name:RUSSELL, KATHRYN A (DC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 S ROSEMARY AVE APT 307
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-5799
Mailing Address - Country:US
Mailing Address - Phone:850-226-3911
Mailing Address - Fax:
Practice Address - Street 1:350 JOHN SIMS PKWY W UNIT 401
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1963
Practice Address - Country:US
Practice Address - Phone:850-678-8049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-06
Last Update Date:2023-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13696111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor