MEDICARE: DIANA MARIE RUSSELL H.H.P

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	385759-00	CA
2	364SH1100X	Holistic Clinical Nurse Specialist	385759-00	CA

General Provider Information

NPI Number	:	1457674095
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA MARIE RUSSELL H.H.P

Provider Business Mailing Address
First Line	:	7773 UNIVERSITY AVE
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91942-4950
Country	:	US
Telephone Number	:	619-303-5702
Fax Number	:	619-825-8742

Provider Business Practice Location Address
First Line	:	7773 UNIVERSITY AVE
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91942-4950
Country	:	US
Telephone Number	:	619-303-5702
Fax Number	:	619-825-8742

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2010
Last Update Date	:	03/10/2010

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