=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306095443
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. RAQUELLE MONIQUE RUSSELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2008
-----------------------------------------------------
Last Update Date | 12/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4450 BELDEN VILLAGE ST NW STE 306
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44718-2588
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-791-5141
-----------------------------------------------------
Fax | 330-476-2573
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4450 BELDEN VILLAGE ST NW STE 306
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44718-2588
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-791-5141
-----------------------------------------------------
Fax | 330-476-2573
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | APRN.0040868
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------