Provider Demographics
NPI:1598176745
Name:RUSSELL, LESTER LEON
Entity Type:Individual
Prefix:MR
First Name:LESTER
Middle Name:LEON
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 WASHINGTON AVE APT 818
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-4559
Mailing Address - Country:US
Mailing Address - Phone:901-679-5366
Mailing Address - Fax:
Practice Address - Street 1:10111 CAMERON RIDGE TRL
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-7184
Practice Address - Country:US
Practice Address - Phone:901-679-5366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-09
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34105146L00000X
TN13023225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic