Provider Demographics
NPI:1821614371
Name:RUSSELL, LISA EVEALINE (HAB SPEC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:EVEALINE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:HAB SPEC
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 1001
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:WV
Mailing Address - Zip Code:25984-1001
Mailing Address - Country:US
Mailing Address - Phone:304-646-9083
Mailing Address - Fax:
Practice Address - Street 1:804 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:MAXWELTON
Practice Address - State:WV
Practice Address - Zip Code:24957-8066
Practice Address - Country:US
Practice Address - Phone:304-497-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-21
Last Update Date:2020-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist