MEDICARE: PURNELL RUSSELL LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	0019015297	VA

General Provider Information

NPI Number	:	1376011171
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PURNELL RUSSELL LMT

Provider Business Mailing Address
First Line	:	2707 SHIPLEY TER SE APT 2
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20020-1823
Country	:	US
Telephone Number	:	202-246-6601
Fax Number	:

Provider Business Practice Location Address
First Line	:	8507 OXON HILL RD STE 200-33
Second Line	:
City	:	FORT WASHINGTON
State	:	MD
Zip	:	20744-4766
Country	:	US
Telephone Number	:	202-246-6601
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2018
Last Update Date	:	11/09/2018

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