Provider Demographics
NPI:1598887853
Name:RUSSELL, NANCY DEACON (PT)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:DEACON
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 GLYNDON AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2923
Mailing Address - Country:US
Mailing Address - Phone:310-993-5298
Mailing Address - Fax:
Practice Address - Street 1:1030 S ARROYO PKWY
Practice Address - Street 2:SUITE #109
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3214
Practice Address - Country:US
Practice Address - Phone:626-593-2283
Practice Address - Fax:626-593-2284
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA802225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAET580ZMedicare PIN