Provider Demographics
NPI:1528361706
Name:RUSSELL, TORA MARIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:TORA
Middle Name:MARIE
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 1:1555 LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-1427
Mailing Address - Country:US
Mailing Address - Phone:614-542-0916
Mailing Address - Fax:
Practice Address - Street 1:1555 LINWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-1427
Practice Address - Country:US
Practice Address - Phone:614-542-0916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-10
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 098491164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse