Provider Demographics
NPI:1679340442
Name:RUSSELL, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
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 1:69 BUD ST
Mailing Address - Street 2:
Mailing Address - City:FRENCH CREEK
Mailing Address - State:WV
Mailing Address - Zip Code:26218
Mailing Address - Country:US
Mailing Address - Phone:304-516-8208
Mailing Address - Fax:
Practice Address - Street 1:69 BUD ST
Practice Address - Street 2:
Practice Address - City:FRENCH CREEK
Practice Address - State:WV
Practice Address - Zip Code:26218
Practice Address - Country:US
Practice Address - Phone:304-516-8208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker