Provider Demographics
NPI:1457569337
Name:RUSSELL, TANISHA (LPN)
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 PIERCETOWN RD
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08332-7908
Mailing Address - Country:US
Mailing Address - Phone:856-455-8534
Mailing Address - Fax:
Practice Address - Street 1:261 CONNECTICUT DR
Practice Address - Street 2:SUITE 5
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-4177
Practice Address - Country:US
Practice Address - Phone:800-950-6066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse