Provider Demographics
NPI:1780186445
Name:RUSSELL, CHIQUITTA (LPN)
Entity Type:Individual
Prefix:
First Name:CHIQUITTA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 E 114TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108-3744
Mailing Address - Country:US
Mailing Address - Phone:216-322-3909
Mailing Address - Fax:
Practice Address - Street 1:1115 E 114TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108-3744
Practice Address - Country:US
Practice Address - Phone:216-322-3909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.156458.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0407914Medicaid
OH1831631OtherGYPSY'S ANGELS HOME HEALTH CARE LLC
1831631OtherDODD