Provider Demographics
NPI:1578893418
Name:RUSSELL, VALERI RENEE
Entity Type:Individual
Prefix:
First Name:VALERI
Middle Name:RENEE
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 1:2600 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301-5094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 WILSON ST
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-5094
Practice Address - Country:US
Practice Address - Phone:406-233-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-26
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant