Healthcare Provider Details

I. General information

NPI: 1508162991
Provider Name (Legal Business Name): TARA RAY RUSSELL LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 N TAYLOR HOLLOW RD NE
MCCONNELSVILLE OH
43756-9629
US

IV. Provider business mailing address

114 N TAYLOR HOLLOW RD NE
MCCONNELSVILLE OH
43756-9629
US

V. Phone/Fax

Practice location:
  • Phone: 740-651-8876
  • Fax:
Mailing address:
  • Phone: 740-651-8876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number113528
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: