Provider Demographics
NPI:1265944979
Name:RUSSELL-WILLIAMS, JANNELL CHAKAKHAN
Entity type:Individual
Prefix:
First Name:JANNELL
Middle Name:CHAKAKHAN
Last Name:RUSSELL-WILLIAMS
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 1:2194 CHICKCHARNIES
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-5505
Mailing Address - Country:US
Mailing Address - Phone:561-543-3050
Mailing Address - Fax:
Practice Address - Street 1:400 EXECUTIVE CENTER DR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2917
Practice Address - Country:US
Practice Address - Phone:561-429-2401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9214052363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care