Provider Demographics
NPI:1497434757
Name:RUSSELL, LISA NICOLE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:NICOLE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6317 PENNSYLVANIA AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:DISTRICT HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20747-3003
Mailing Address - Country:US
Mailing Address - Phone:240-470-6019
Mailing Address - Fax:
Practice Address - Street 1:3001 BLADENSBURG RD NE # 101
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2235
Practice Address - Country:US
Practice Address - Phone:202-635-5767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2023-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator