Provider Demographics
NPI:1811121551
Name:RUSSELL, REGINALD TAYLOR II (NP)
Entity type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:TAYLOR
Last Name:RUSSELL
Suffix:II
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ROCKLAND TER
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-2053
Mailing Address - Country:US
Mailing Address - Phone:804-304-4884
Mailing Address - Fax:
Practice Address - Street 1:1919 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-4269
Practice Address - Country:US
Practice Address - Phone:757-223-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-11
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2008010430171000000X
286500000X
VA0024178243363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No171000000XOther Service ProvidersMilitary Health Care Provider
No286500000XHospitalsMilitary Hospital