Provider Demographics
NPI:1235490616
Name:RUSSELL, SERENA (LM, CPM)
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3409
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95063-3409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 OCEAN ST STE A
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-6628
Practice Address - Country:US
Practice Address - Phone:707-484-3403
Practice Address - Fax:831-295-6706
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-02
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA472176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife