Healthcare Provider Details

I. General information

NPI: 1912979253
Provider Name (Legal Business Name): REBECCA A RUSSEL ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 11/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 LILLY RD NE
OLYMPIA WA
98506-5133
US

IV. Provider business mailing address

413 LILLY RD NE
OLYMPIA WA
98506-5133
US

V. Phone/Fax

Practice location:
  • Phone: 360-486-3537
  • Fax: 360-486-6447
Mailing address:
  • Phone: 360-486-3537
  • Fax: 360-486-6447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP30002233
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: