Provider Demographics
NPI:1881358943
Name:RUSSUM, SERENA LYNN (ND)
Entity type:Individual
Prefix:
First Name:SERENA
Middle Name:LYNN
Last Name:RUSSUM
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 NE 112TH AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-5115
Mailing Address - Country:US
Mailing Address - Phone:360-207-5178
Mailing Address - Fax:
Practice Address - Street 1:811 NE 112TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-5115
Practice Address - Country:US
Practice Address - Phone:360-207-5178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4434175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath