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General NPI Number Information
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NPI Number | 1669538880
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Entity Type | Individual
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Provider Name | ANDREA SUSAN RUSSELL LAC, MACOM
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Gender | Female
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Dates
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Enumeration Date | 12/29/2006
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Last Update Date | 08/15/2011
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Provider Practice Location Address
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Address Line | 5410 CALIFORNIA AVE SW #203
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City | SEATTLE
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State | WA
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Zip | 98136-1562
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Country | US
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Telephone | 206-200-3595
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Fax |
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Provider Business Mailing Address
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Address Line | 3206 46TH AVE SW
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City | SEATTLE
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State | WA
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Zip | 98116-3333
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Country | US
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Telephone | 206-200-3595
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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 | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | AC00002906
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License Number State | WA
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