Provider Demographics
NPI:1457674095
Name:RUSSELL, DIANA MARIE (HHP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:HHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7773 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-4950
Mailing Address - Country:US
Mailing Address - Phone:619-303-5702
Mailing Address - Fax:619-825-8742
Practice Address - Street 1:7773 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-4950
Practice Address - Country:US
Practice Address - Phone:619-303-5702
Practice Address - Fax:619-825-8742
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA385759-00225700000X, 364SH1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SH1100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHolistic
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist