Healthcare Provider Details

I. General information

NPI: 1659761070
Provider Name (Legal Business Name): NIKKI RUSSELL RN, BSN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2015
Last Update Date: 01/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3179 APPLE RD NE
WASHINGTON DC
20018-1605
US

IV. Provider business mailing address

3179 APPLE RD NE
WASHINGTON DC
20018-1605
US

V. Phone/Fax

Practice location:
  • Phone: 202-664-4146
  • Fax:
Mailing address:
  • Phone: 202-664-4146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number1008722
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: