Healthcare Provider Details

I. General information

NPI: 1548773625
Provider Name (Legal Business Name): KELLY RUSSELL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2017
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5982 RHODES RD
KENT OH
44240-8100
US

IV. Provider business mailing address

5982 RHODES RD
KENT OH
44240-8100
US

V. Phone/Fax

Practice location:
  • Phone: 330-673-1347
  • Fax:
Mailing address:
  • Phone: 330-673-1347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN.412637
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: