Provider Demographics
NPI:1275664633
Name:RUSSELL, TINA MARIE
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:DUNNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1812
Mailing Address - Street 2:
Mailing Address - City:VALDEZ
Mailing Address - State:AK
Mailing Address - Zip Code:99686
Mailing Address - Country:US
Mailing Address - Phone:907-835-4480
Mailing Address - Fax:
Practice Address - Street 1:218 CHENEGA ST
Practice Address - Street 2:SUITE A
Practice Address - City:VALDEZ
Practice Address - State:AK
Practice Address - Zip Code:99686
Practice Address - Country:US
Practice Address - Phone:907-835-3274
Practice Address - Fax:907-835-3574
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator