Provider Demographics
NPI:1821404666
Name:RUSSELL, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
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 1:10785 ARROYO AVE
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-2503
Mailing Address - Country:US
Mailing Address - Phone:916-396-6306
Mailing Address - Fax:
Practice Address - Street 1:9898 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-2968
Practice Address - Country:US
Practice Address - Phone:760-244-9898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000035532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer