Healthcare Provider Details

I. General information

NPI: 1518084300
Provider Name (Legal Business Name): DIANE L RUSSELL L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19007 NE DAVIS RD
BRUSH PRAIRIE WA
98606-8756
US

IV. Provider business mailing address

19007 NE DAVIS RD
BRUSH PRAIRIE WA
98606-8756
US

V. Phone/Fax

Practice location:
  • Phone: 360-254-0238
  • Fax:
Mailing address:
  • Phone: 360-254-0238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00003008
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: