Healthcare Provider Details

I. General information

NPI: 1750683769
Provider Name (Legal Business Name): NANCY JO RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2010
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 US HIGHWAY 95A S STE I 901
FERNLEY NV
89408-9261
US

IV. Provider business mailing address

1665 OLD HOT SPRINGS RD STE 157
CARSON CITY NV
89706-0782
US

V. Phone/Fax

Practice location:
  • Phone: 775-575-7744
  • Fax: 775-575-7769
Mailing address:
  • Phone: 775-687-5162
  • Fax: 775-687-1214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: