Provider Demographics
NPI:1407478100
Name:CROTEAU, RUSSELL (RN)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:CROTEAU
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3259 ACACIA ST
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-2539
Mailing Address - Country:US
Mailing Address - Phone:858-431-9609
Mailing Address - Fax:
Practice Address - Street 1:3259 ACACIA ST
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-2539
Practice Address - Country:US
Practice Address - Phone:858-431-9609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA688730163WH0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0500XNursing Service ProvidersRegistered NurseHemodialysis