Provider Demographics
NPI:1376011171
Name:RUSSELL, PURNELL (LMT)
Entity Type:Individual
Prefix:
First Name:PURNELL
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 SHIPLEY TER SE APT 2
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-1823
Mailing Address - Country:US
Mailing Address - Phone:202-246-6601
Mailing Address - Fax:
Practice Address - Street 1:8507 OXON HILL RD STE 200-33
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-4766
Practice Address - Country:US
Practice Address - Phone:202-246-6601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019015297225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist