Provider Demographics
NPI:1639661192
Name:RUSSELL, KENNETH LEE (NAVY SOIDC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LEE
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:NAVY SOIDC
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:HM1 RUSSELL KENNETH
Mailing Address - Street 1:1101 MAREN CV APT 102
Mailing Address - Street 2:
Mailing Address - City:SNEADS FERRY
Mailing Address - State:NC
Mailing Address - Zip Code:28460-0080
Mailing Address - Country:US
Mailing Address - Phone:360-808-1590
Mailing Address - Fax:
Practice Address - Street 1:3D MARINE RAIDER BATTALION
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28546
Practice Address - Country:US
Practice Address - Phone:360-808-1590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
1391428740OtherNAVY/DOD