Healthcare Provider Details

I. General information

NPI: 1417898685
Provider Name (Legal Business Name): MS. NATASHA CORIELL RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 FRAZEE RD
SAN DIEGO CA
92108-4347
US

IV. Provider business mailing address

310 A ST
SAN DIEGO CA
92101-4258
US

V. Phone/Fax

Practice location:
  • Phone: 619-393-3909
  • Fax:
Mailing address:
  • Phone: 619-710-3858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN95240535
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: