Healthcare Provider Details

I. General information

NPI: 1326541798
Provider Name (Legal Business Name): CELENA RUSS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 03/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 SUSHRUTA DR STE D
MARTINSBURG WV
25401-8801
US

IV. Provider business mailing address

395 TEAL RD N
MARTINSBURG WV
25405-8385
US

V. Phone/Fax

Practice location:
  • Phone: 304-262-2538
  • Fax: 304-262-2583
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number85629
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: