Healthcare Provider Details

I. General information

NPI: 1639408560
Provider Name (Legal Business Name): RUSSELL EVERETT LOVEJOY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/24/2009
Last Update Date: 12/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 E LAKELAND DR
PANAMA CITY FL
32404-4248
US

IV. Provider business mailing address

4515 E LAKELAND DR
PANAMA CITY FL
32404
US

V. Phone/Fax

Practice location:
  • Phone: 850-319-5776
  • Fax:
Mailing address:
  • Phone: 850-319-5776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: