Provider Demographics
NPI:1790425551
Name:RUSSELL, STEPHANIE ANN (RN, LMT)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ANN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RN, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1851
Mailing Address - Street 2:
Mailing Address - City:MANNFORD
Mailing Address - State:OK
Mailing Address - Zip Code:74044-1851
Mailing Address - Country:US
Mailing Address - Phone:918-330-3835
Mailing Address - Fax:
Practice Address - Street 1:35266 W HWY 33
Practice Address - Street 2:
Practice Address - City:MANNFORD
Practice Address - State:OK
Practice Address - Zip Code:74044
Practice Address - Country:US
Practice Address - Phone:918-330-3835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR132210163W00000X
OK190284-0225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No163W00000XNursing Service ProvidersRegistered Nurse