Provider Demographics
NPI:1639933484
Name:RUSSELL, DANIEL JAMES (NP)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JAMES
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8610 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2435
Mailing Address - Country:US
Mailing Address - Phone:262-939-4744
Mailing Address - Fax:
Practice Address - Street 1:677 E STATE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1639
Practice Address - Country:US
Practice Address - Phone:262-763-9531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13237-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner