Provider Demographics
NPI:1639839830
Name:RUSSELL, PATRICIA ANN
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:ANN
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 1:1391 NW 136TH AVE
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2800
Mailing Address - Country:US
Mailing Address - Phone:615-268-2177
Mailing Address - Fax:770-723-8428
Practice Address - Street 1:1391 NW 136TH AVE
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2800
Practice Address - Country:US
Practice Address - Phone:615-268-2177
Practice Address - Fax:770-723-8428
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN75570163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management