Provider Demographics
NPI:1477806396
Name:RUSSELL, SUSAN KAY (LPN)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:KAY
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 1:913 W HOLMES RD STE 189
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-0434
Mailing Address - Country:US
Mailing Address - Phone:517-272-4357
Mailing Address - Fax:517-272-4358
Practice Address - Street 1:913 W HOLMES RD STE 189
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-0434
Practice Address - Country:US
Practice Address - Phone:517-272-4357
Practice Address - Fax:517-272-4358
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703043851164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse