Provider Demographics
NPI:1417467150
Name:RUSS, THEODORIA (STNA)
Entity Type:Individual
Prefix:
First Name:THEODORIA
Middle Name:
Last Name:RUSS
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 CABOT ST
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44509-1405
Mailing Address - Country:US
Mailing Address - Phone:330-792-7629
Mailing Address - Fax:330-782-7858
Practice Address - Street 1:349 CABOT ST
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44509-1405
Practice Address - Country:US
Practice Address - Phone:330-792-7629
Practice Address - Fax:330-782-7858
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH375819830896374U00000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCS1725500OtherMY OHIO CARE SOURCE
OH0216072Medicaid