Healthcare Provider Details

I. General information

NPI: 1851110894
Provider Name (Legal Business Name): MICHAELA RUSS RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 09/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4375 DUPLIN COUNTY RD
PINK HILL NC
28572-9684
US

IV. Provider business mailing address

4375 DUPLIN COUNTY RD
PINK HILL NC
28572-9684
US

V. Phone/Fax

Practice location:
  • Phone: 252-526-8184
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-315872
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: