Provider Demographics
NPI:1013511708
Name:RUSSELL, TIMOTHY RYAN
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RYAN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 SAM DAMRON CEMETERY RD
Mailing Address - Street 2:
Mailing Address - City:DUNLOW
Mailing Address - State:WV
Mailing Address - Zip Code:25511-8267
Mailing Address - Country:US
Mailing Address - Phone:304-385-9068
Mailing Address - Fax:
Practice Address - Street 1:235 SAM DAMRON CEMETERY RD
Practice Address - Street 2:
Practice Address - City:DUNLOW
Practice Address - State:WV
Practice Address - Zip Code:25511-8267
Practice Address - Country:US
Practice Address - Phone:304-385-9068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant