Provider Demographics
NPI:1801786538
Name:RUSSELL, MICA
Entity type:Individual
Prefix:
First Name:MICA
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 1:2731 HILLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2753
Mailing Address - Country:US
Mailing Address - Phone:606-547-1902
Mailing Address - Fax:
Practice Address - Street 1:2731 HILLVIEW DR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2753
Practice Address - Country:US
Practice Address - Phone:606-547-1902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-04
Last Update Date:2025-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH129436164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse