Provider Demographics
NPI:1457751455
Name:RUSSELL, KALIN A
Entity Type:Individual
Prefix:
First Name:KALIN
Middle Name:A
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 1:962 MILDRED DR
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-5044
Mailing Address - Country:US
Mailing Address - Phone:516-680-9759
Mailing Address - Fax:
Practice Address - Street 1:962 MILDRED DR
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-5044
Practice Address - Country:US
Practice Address - Phone:516-680-9759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer