Provider Demographics
NPI:1598543621
Name:RUSSELL, LILY MARIE
Entity Type:Individual
Prefix:
First Name:LILY
Middle Name:MARIE
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 1:1109 TURNER ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-6426
Mailing Address - Country:US
Mailing Address - Phone:207-513-2896
Mailing Address - Fax:
Practice Address - Street 1:716 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2656
Practice Address - Country:US
Practice Address - Phone:207-283-0171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program