Healthcare Provider Details

I. General information

NPI: 1033541081
Provider Name (Legal Business Name): MONIQUE YEVETTE RUSS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MONIQUE YEVETTE FARMER RN

II. Dates (important events)

Enumeration Date: 08/01/2013
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1522 N 33RD ST
MILWAUKEE WI
53208-2301
US

IV. Provider business mailing address

1522 N 33RD ST
MILWAUKEE WI
53208-2301
US

V. Phone/Fax

Practice location:
  • Phone: 414-254-8650
  • Fax:
Mailing address:
  • Phone: 414-254-8650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number224762-30
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number224762-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: