Healthcare Provider Details

I. General information

NPI: 1275044463
Provider Name (Legal Business Name): CHRISTINE MARIE RUSSELL LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2017
Last Update Date: 10/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 NORTHLAND DR STE 200A
MEDINA OH
44256-3440
US

IV. Provider business mailing address

246 NORTHLAND DR STE 200A
MEDINA OH
44256-3440
US

V. Phone/Fax

Practice location:
  • Phone: 330-725-9195
  • Fax: 330-725-9187
Mailing address:
  • Phone: 330-725-9195
  • Fax: 330-725-9187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.147381-MEDS-IV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: