Provider Demographics
NPI:1255741740
Name:RUSSELL, SHUNETHY
Entity type:Individual
Prefix:
First Name:SHUNETHY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 OLD NEW BRUNSWICK RD
Mailing Address - Street 2:APT 2
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854
Mailing Address - Country:US
Mailing Address - Phone:908-868-7380
Mailing Address - Fax:
Practice Address - Street 1:72 OLD NEW BRUNSWICK RD
Practice Address - Street 2:2
Practice Address - City:PISCATAWAY
Practice Address - State:NJ
Practice Address - Zip Code:08854-3885
Practice Address - Country:US
Practice Address - Phone:908-868-7380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00447100225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist