Provider Demographics
NPI:1285211268
Name:RUSSELL, LATOYA JASAN (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:LATOYA
Middle Name:JASAN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 BENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-3002
Mailing Address - Country:US
Mailing Address - Phone:419-303-0863
Mailing Address - Fax:
Practice Address - Street 1:835 N LOCUST ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:OH
Practice Address - Zip Code:45875-1216
Practice Address - Country:US
Practice Address - Phone:419-523-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.344735163W00000X
OHAPRN.CNP.0030845363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse