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General NPI Number Information
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NPI Number | 1457743916
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Entity Type | Individual
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Provider Name | ANTOINETTE RUSSELL
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Gender | Female
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Dates
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Enumeration Date | 02/20/2015
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Last Update Date | 02/20/2015
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Provider Practice Location Address
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Address Line | 2922 W WHITE MOUNTAIN BLVD
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City | LAKESIDE
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State | AZ
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Zip | 85929-6152
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Country | US
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Telephone | 928-368-6112
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Fax | 928-368-5643
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Provider Business Mailing Address
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Address Line | 2922 W WHITE MOUNTAIN BLVD
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City | LAKESIDE
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State | AZ
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Zip | 85929-6152
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Country | US
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Telephone | 928-368-6112
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Fax | 928-368-5643
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 146L00000X
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Taxonomy Name | Paramedic
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License Number | 111
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 146N00000X
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Taxonomy Name | Basic Emergency Medical Technician
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License Number | 111
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License Number State | AZ
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