Provider Demographics
NPI:1275888042
Name:RUSSELL, DIONICIA M (RN)
Entity Type:Individual
Prefix:
First Name:DIONICIA
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 W ELM RD
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-2111
Mailing Address - Country:US
Mailing Address - Phone:270-312-0364
Mailing Address - Fax:
Practice Address - Street 1:CMR 411 BLDG 700 ROSE BARRACKS
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09112
Practice Address - Country:US
Practice Address - Phone:49966-283-4719
Practice Address - Fax:49966-283-4721
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1088555163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN