Healthcare Provider Details

I. General information

NPI: 1801774393
Provider Name (Legal Business Name): DESTINY RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2025
Last Update Date: 08/23/2025
Certification Date: 08/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26350 DELANO DR SPC 74
IDYLLWILD CA
92549-2631
US

IV. Provider business mailing address

PO BOX 99
MOUNTAIN CENTER CA
92561-0099
US

V. Phone/Fax

Practice location:
  • Phone: 840-250-8641
  • Fax:
Mailing address:
  • Phone: 840-250-8641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: