Healthcare Provider Details

I. General information

NPI: 1306095443
Provider Name (Legal Business Name): MRS. RAQUELLE MONIQUE RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 BELDEN VILLAGE ST NW STE 306
CANTON OH
44718-2588
US

IV. Provider business mailing address

4450 BELDEN VILLAGE ST NW STE 306
CANTON OH
44718-2588
US

V. Phone/Fax

Practice location:
  • Phone: 330-791-5141
  • Fax: 330-476-2573
Mailing address:
  • Phone: 330-791-5141
  • Fax: 330-476-2573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.0040868
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: