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General NPI Number Information
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NPI Number | 1598887853
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Entity Type | Individual
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Provider Name | NANCY DEACON RUSSELL P.T.
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Gender | Female
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Dates
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Enumeration Date | 04/05/2007
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Last Update Date | 04/26/2011
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Provider Practice Location Address
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Address Line | 1030 S ARROYO PKWY SUITE #109
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City | PASADENA
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State | CA
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Zip | 91105-3214
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Country | US
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Telephone | 626-593-2283
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Fax | 626-593-2284
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Provider Business Mailing Address
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Address Line | 1621 GLYNDON AVE
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City | VENICE
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State | CA
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Zip | 90291-2923
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Country | US
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Telephone | 310-993-5298
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Fax |
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 802
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License Number State | CA
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