Healthcare Provider Details

I. General information

NPI: 1598531683
Provider Name (Legal Business Name): MARI RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2023
Last Update Date: 09/29/2024
Certification Date: 09/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23511 CHAGRIN BLVD APT 417
BEACHWOOD OH
44122-5539
US

IV. Provider business mailing address

23511 CHAGRIN BLVD
BEACHWOOD OH
44122-5528
US

V. Phone/Fax

Practice location:
  • Phone: 216-507-1747
  • Fax:
Mailing address:
  • Phone: 216-856-2582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number401390360512
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: