Healthcare Provider Details

I. General information

NPI: 1538483516
Provider Name (Legal Business Name): CAITLYN RUSSELL AD OF NURSING
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2010
Last Update Date: 03/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 FOREST PARK DR APT. D
HAMILTON OH
45011-0834
US

IV. Provider business mailing address

60 FOREST PARK DR APT. D
HAMILTON OH
45011-0834
US

V. Phone/Fax

Practice location:
  • Phone: 513-253-2454
  • Fax:
Mailing address:
  • Phone: 513-253-2454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number358321
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: