Provider Demographics
NPI:1609159243
Name:RUSS, SHELLY B (LPN)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:B
Last Name:RUSS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6495 JULIAN RD SW
Mailing Address - Street 2:
Mailing Address - City:AMANDA
Mailing Address - State:OH
Mailing Address - Zip Code:43102-9527
Mailing Address - Country:US
Mailing Address - Phone:740-969-4499
Mailing Address - Fax:
Practice Address - Street 1:6495 JULIAN RD SW
Practice Address - Street 2:
Practice Address - City:AMANDA
Practice Address - State:OH
Practice Address - Zip Code:43102-9527
Practice Address - Country:US
Practice Address - Phone:740-969-4499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH144348164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse