Provider Demographics
NPI:1780808907
Name:RUSSELL, DONNA REVES (NNP)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:REVES
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 BLAIR RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-3605
Mailing Address - Country:US
Mailing Address - Phone:540-342-7942
Mailing Address - Fax:
Practice Address - Street 1:101 ELM AVE SE
Practice Address - Street 2:CARILION ROANOKE COMMUNITY - NICU, 6TH AND 9TH FLOOR
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-2222
Practice Address - Country:US
Practice Address - Phone:540-985-8051
Practice Address - Fax:540-985-8005
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001116283363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE