Provider Demographics
NPI:1134944879
Name:RUSSELL, CHARITY DENEISE (LPN)
Entity type:Individual
Prefix:
First Name:CHARITY
Middle Name:DENEISE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12501 NW 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98685-2416
Mailing Address - Country:US
Mailing Address - Phone:360-773-7927
Mailing Address - Fax:
Practice Address - Street 1:12501 NW 19TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2416
Practice Address - Country:US
Practice Address - Phone:360-773-7927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP60300776164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse