Provider Demographics
NPI:1245221217
Name:BOERSMA, RUSSELL ROY (LPN)
Entity Type:Individual
Prefix:MRS
First Name:RUSSELL
Middle Name:ROY
Last Name:BOERSMA
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 TAVERN RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-8814
Mailing Address - Country:US
Mailing Address - Phone:540-657-8750
Mailing Address - Fax:
Practice Address - Street 1:9501 FARRELL RD
Practice Address - Street 2:
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-5901
Practice Address - Country:US
Practice Address - Phone:703-805-0599
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA159452164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse