Provider Demographics
NPI:1669634655
Name:RUSSELL, MEGZIE YVONNE
Entity Type:Individual
Prefix:
First Name:MEGZIE
Middle Name:YVONNE
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 1:1902 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-1006
Mailing Address - Country:US
Mailing Address - Phone:239-368-9538
Mailing Address - Fax:239-368-1472
Practice Address - Street 1:1902 E 6TH ST
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-1006
Practice Address - Country:US
Practice Address - Phone:239-368-9538
Practice Address - Fax:239-368-1472
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6905982171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL142739300Medicaid