Healthcare Provider Details

I. General information

NPI: 1366350357
Provider Name (Legal Business Name): LISA RUSSELL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5260 78TH AVE N
PINELLAS PARK FL
33780-8140
US

IV. Provider business mailing address

5260 78TH AVE N UNIT 1697
PINELLAS PARK FL
33780-8068
US

V. Phone/Fax

Practice location:
  • Phone: 850-322-6745
  • Fax:
Mailing address:
  • Phone: 888-958-1382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95323427
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9310892
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: