Provider Demographics
NPI:1275194177
Name:RUSSELL, LAUREN ANN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ANN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LINCOLN AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-4908
Mailing Address - Country:US
Mailing Address - Phone:707-255-3719
Mailing Address - Fax:
Practice Address - Street 1:1100 LINCOLN AVE STE 108
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-4908
Practice Address - Country:US
Practice Address - Phone:707-255-3719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-22
Last Update Date:2019-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker