Provider Demographics
NPI:1306417399
Name:RUSSELL, MCKEEG (CNA)
Entity Type:Individual
Prefix:
First Name:MCKEEG
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26045 WOODARD AVE
Mailing Address - Street 2:
Mailing Address - City:MOFFAT
Mailing Address - State:CO
Mailing Address - Zip Code:81143-9782
Mailing Address - Country:US
Mailing Address - Phone:719-221-6224
Mailing Address - Fax:
Practice Address - Street 1:26045 WOODARD AVE
Practice Address - Street 2:
Practice Address - City:MOFFAT
Practice Address - State:CO
Practice Address - Zip Code:81143-9782
Practice Address - Country:US
Practice Address - Phone:719-221-6224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTNA00003041376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide