Healthcare Provider Details

I. General information

NPI: 1780808907
Provider Name (Legal Business Name): DONNA REVES RUSSELL NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 ELM AVE SE CARILION ROANOKE COMMUNITY - NICU, 6TH AND 9TH FLOOR
ROANOKE VA
24013-2222
US

IV. Provider business mailing address

1701 BLAIR RD SW
ROANOKE VA
24015-3605
US

V. Phone/Fax

Practice location:
  • Phone: 540-985-8051
  • Fax: 540-985-8005
Mailing address:
  • Phone: 540-342-7942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number0001116283
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: