Provider Demographics
NPI:1205660248
Name:RUSSELL, RALPH WILLIAM II
Entity type:Individual
Prefix:MR
First Name:RALPH
Middle Name:WILLIAM
Last Name:RUSSELL
Suffix:II
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 1:4108 SAN MARCO DR
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-6194
Mailing Address - Country:US
Mailing Address - Phone:804-998-7398
Mailing Address - Fax:804-597-6413
Practice Address - Street 1:4108 SAN MARCO DR
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-6194
Practice Address - Country:US
Practice Address - Phone:804-998-7398
Practice Address - Fax:804-597-6413
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide