Healthcare Provider Details

I. General information

NPI: 1215643903
Provider Name (Legal Business Name): JANICE LYNN RUSSELL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 TYSONS BLVD STE 1400
MC LEAN VA
22102-4893
US

IV. Provider business mailing address

1600 TYSONS BLVD STE 1400
MC LEAN VA
22102-4893
US

V. Phone/Fax

Practice location:
  • Phone: 267-221-2658
  • Fax:
Mailing address:
  • Phone: 800-367-5690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN529580L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: