Healthcare Provider Details

I. General information

NPI: 1821818857
Provider Name (Legal Business Name): INAE RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 FITZWATERTOWN RD STE 1
WILLOW GROVE PA
19090-1338
US

IV. Provider business mailing address

735 FITZWATERTOWN RD STE 1
WILLOW GROVE PA
19090-1338
US

V. Phone/Fax

Practice location:
  • Phone: 215-657-2012
  • Fax:
Mailing address:
  • Phone: 215-657-2012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberSP030858
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: