Healthcare Provider Details

I. General information

NPI: 1922201169
Provider Name (Legal Business Name): BRENDA NOVELLA RUSSELL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 JEFFERSON AVE MCDONALD ARMY HEALTH CENTER
FORT EUSTIS VA
23604-5548
US

IV. Provider business mailing address

168 EASY ST
DUTTON VA
23050-9734
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7522
  • Fax:
Mailing address:
  • Phone: 804-725-7885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0024138348
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: