Healthcare Provider Details

I. General information

NPI: 1457674095
Provider Name (Legal Business Name): DIANA MARIE RUSSELL H.H.P
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 03/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7773 UNIVERSITY AVE
LA MESA CA
91942-4950
US

IV. Provider business mailing address

7773 UNIVERSITY AVE
LA MESA CA
91942-4950
US

V. Phone/Fax

Practice location:
  • Phone: 619-303-5702
  • Fax: 619-825-8742
Mailing address:
  • Phone: 619-303-5702
  • Fax: 619-825-8742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SH1100X
TaxonomyHolistic Clinical Nurse Specialist
License Number385759-00
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number385759-00
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: