Provider Demographics
NPI:1265664981
Name:RUSSELL, KIM A (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:A
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 DAVID RHODES ROAD
Mailing Address - Street 2:PO BOX 605
Mailing Address - City:WESTBROOKEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12785-0605
Mailing Address - Country:US
Mailing Address - Phone:845-754-8173
Mailing Address - Fax:
Practice Address - Street 1:99 DAVID RHODES ROAD
Practice Address - Street 2:
Practice Address - City:WESTBROOKEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12785-0605
Practice Address - Country:US
Practice Address - Phone:845-754-8173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY268453164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse