Provider Demographics
NPI:1518084300
Name:RUSSELL, DIANE L (LAC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19007 NE DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:BRUSH PRAIRIE
Mailing Address - State:WA
Mailing Address - Zip Code:98606-8756
Mailing Address - Country:US
Mailing Address - Phone:360-254-0238
Mailing Address - Fax:
Practice Address - Street 1:19007 NE DAVIS RD
Practice Address - Street 2:
Practice Address - City:BRUSH PRAIRIE
Practice Address - State:WA
Practice Address - Zip Code:98606-8756
Practice Address - Country:US
Practice Address - Phone:360-254-0238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC00003008171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist