Provider Demographics
NPI:1760663819
Name:RUSS, PAMELA SULLIVAN (LP, RN)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SULLIVAN
Last Name:RUSS
Suffix:
Gender:F
Credentials:LP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8420 DELANEY COURT
Mailing Address - Street 2:
Mailing Address - City:INVER GROVE HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55076
Mailing Address - Country:US
Mailing Address - Phone:651-455-3162
Mailing Address - Fax:
Practice Address - Street 1:8420 DELANEY CT
Practice Address - Street 2:
Practice Address - City:INVER GROVE HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55076-3425
Practice Address - Country:US
Practice Address - Phone:651-455-3162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3039103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical