Provider Demographics
NPI:1417727132
Name:RUSSELL, LATONYA MICHELLE (RN)
Entity Type:Individual
Prefix:
First Name:LATONYA
Middle Name:MICHELLE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 CAROLINA ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46407-2346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1623 CAROLINA ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46407-2346
Practice Address - Country:US
Practice Address - Phone:219-771-0689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28273063A163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Single Specialty