Provider Demographics
NPI:1578000204
Name:PERRY-RUSSELL, ANGELLIQUE
Entity Type:Individual
Prefix:MRS
First Name:ANGELLIQUE
Middle Name:
Last Name:PERRY-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 1:6425 JOLIET RD APT 1WF
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE HIGHLANDS
Mailing Address - State:IL
Mailing Address - Zip Code:60525-4293
Mailing Address - Country:US
Mailing Address - Phone:708-288-8445
Mailing Address - Fax:
Practice Address - Street 1:6425 JOLIET RD APT 1WF
Practice Address - Street 2:
Practice Address - City:LA GRANGE HIGHLANDS
Practice Address - State:IL
Practice Address - Zip Code:60525-4293
Practice Address - Country:US
Practice Address - Phone:708-288-8445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL85-2543203OtherIRS