Healthcare Provider Details

I. General information

NPI: 1508268467
Provider Name (Legal Business Name): AWANYA DELORES RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8912 VOLUNTEER LN
SACRAMENTO CA
95826-3221
US

IV. Provider business mailing address

8912 VOLUNTEER LN
SACRAMENTO CA
95826-3221
US

V. Phone/Fax

Practice location:
  • Phone: 916-869-3210
  • Fax: 916-344-0196
Mailing address:
  • Phone: 916-869-3210
  • Fax: 916-344-0196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: