Provider Demographics
NPI:1477167666
Name:RUSSELL, DAVID JOSEPH (PMHNP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOSEPH
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17846 GLENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-9521
Mailing Address - Country:US
Mailing Address - Phone:650-274-4324
Mailing Address - Fax:
Practice Address - Street 1:17846 GLENWOOD RD
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-9521
Practice Address - Country:US
Practice Address - Phone:866-931-2587
Practice Address - Fax:866-380-0676
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95039943363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty