Provider Demographics
NPI:1922201169
Name:RUSSELL, BRENDA NOVELLA (NP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:NOVELLA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 EASY ST
Mailing Address - Street 2:
Mailing Address - City:DUTTON
Mailing Address - State:VA
Mailing Address - Zip Code:23050-9734
Mailing Address - Country:US
Mailing Address - Phone:804-725-7885
Mailing Address - Fax:
Practice Address - Street 1:576 JEFFERSON AVE
Practice Address - Street 2:MCDONALD ARMY HEALTH CENTER
Practice Address - City:FORT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-5548
Practice Address - Country:US
Practice Address - Phone:757-314-7522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024138348363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health