Provider Demographics
NPI:1508462193
Name:RUSSELL, DONNA K
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:K
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 1:702 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-5114
Mailing Address - Country:US
Mailing Address - Phone:740-353-8262
Mailing Address - Fax:
Practice Address - Street 1:702 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-5114
Practice Address - Country:US
Practice Address - Phone:740-353-8262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7304250376J00000X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0246342Medicaid