Provider Demographics
NPI:1619153491
Name:RUSSELL, LINDA (LPN)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:RUSSELL
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 1:2575 N COURTENAY PKWY
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4126
Mailing Address - Country:US
Mailing Address - Phone:321-639-7639
Mailing Address - Fax:321-639-5762
Practice Address - Street 1:2575 N COURTENAY PKWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4126
Practice Address - Country:US
Practice Address - Phone:321-639-7639
Practice Address - Fax:321-639-5762
Is Sole Proprietor?:No
Enumeration Date:2008-01-11
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN 5166225164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse