Healthcare Provider Details

I. General information

NPI: 1184950313
Provider Name (Legal Business Name): KATHRYN JOY RUSSELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2009
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 VENETIAN COURT SUITE 1
NAPLES FL
34109
US

IV. Provider business mailing address

2235 VENETIAN COURT SUITE 1
NAPLES FL
34109
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-6268
  • Fax:
Mailing address:
  • Phone: 239-596-9337
  • Fax: 239-596-9466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number115577
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number115577
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number115577
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number115577
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: