Provider Demographics
NPI:1396485918
Name:RUSSELL, KIMBERLY DAWN
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
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 1:2157 GREENBRIER ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-9623
Mailing Address - Country:US
Mailing Address - Phone:304-344-5924
Mailing Address - Fax:
Practice Address - Street 1:2157 GREENBRIER ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-9623
Practice Address - Country:US
Practice Address - Phone:304-344-5924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV33364164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1255349726Medicaid