Provider Demographics
NPI:1306402938
Name:RUSSELL, KATHY DEANN
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:DEANN
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 1:418 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-1712
Mailing Address - Country:US
Mailing Address - Phone:740-776-2785
Mailing Address - Fax:
Practice Address - Street 1:418 CENTER ST
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-1712
Practice Address - Country:US
Practice Address - Phone:740-776-2785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH136137164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse