Provider Demographics
NPI:1508162991
Name:RUSSELL, TARA RAY (LPN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:RAY
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 N TAYLOR HOLLOW RD NE
Mailing Address - Street 2:
Mailing Address - City:MCCONNELSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43756-9629
Mailing Address - Country:US
Mailing Address - Phone:740-651-8876
Mailing Address - Fax:
Practice Address - Street 1:114 N TAYLOR HOLLOW RD NE
Practice Address - Street 2:
Practice Address - City:MCCONNELSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43756-9629
Practice Address - Country:US
Practice Address - Phone:740-651-8876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-01
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH113528164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse