Provider Demographics
NPI:1245669498
Name:RUSSELL, REBECCA
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:HUSSAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:4210 LAKE BOONE TRL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6521
Mailing Address - Country:US
Mailing Address - Phone:919-784-6600
Mailing Address - Fax:
Practice Address - Street 1:4210 LAKE BOONE TRL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6521
Practice Address - Country:US
Practice Address - Phone:919-784-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-08
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF-338111-1363LF0000X
NC5017539208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily