Provider Demographics
NPI:1740747740
Name:RUSS, CHENELLE DOMINIQUE (STNA)
Entity Type:Individual
Prefix:MS
First Name:CHENELLE
Middle Name:DOMINIQUE
Last Name:RUSS
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 MAIN ST APT 7
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-7801
Mailing Address - Country:US
Mailing Address - Phone:513-692-0926
Mailing Address - Fax:
Practice Address - Street 1:1409 MAIN ST APT 7
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45202-7801
Practice Address - Country:US
Practice Address - Phone:513-692-0926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401270100711376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide