Healthcare Provider Details

I. General information

NPI: 1427982305
Provider Name (Legal Business Name): KHULTHUM RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12883 OLD GLORY DR
FISHERS IN
46037-7188
US

IV. Provider business mailing address

12883 OLD GLORY DR
FISHERS IN
46037-7188
US

V. Phone/Fax

Practice location:
  • Phone: 317-768-0978
  • Fax:
Mailing address:
  • Phone: 317-768-0978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT22508776
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: