Provider Demographics
NPI:1326538638
Name:RUSSELL, FAWN
Entity Type:Individual
Prefix:
First Name:FAWN
Middle Name:
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:PO BOX 6255
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61204-6255
Mailing Address - Country:US
Mailing Address - Phone:414-429-3332
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:490 AVENUE OF THE CITIES
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-4031
Practice Address - Country:US
Practice Address - Phone:309-796-1251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-11
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA091685235Z00000X
IL146.015288235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist