MEDICARE: MRS. NANCY J RUSSELL MS, PT

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	225100000X	Physical Therapist	PT00008393	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5872RU	OTHER	WA	REGENCE BS
2	157404	OTHER	WA	DEPT. OF LABOR AND INDUST
3	650022436	OTHER	WA	R/R MED PC
4	650022435	OTHER	WA	R/R MED KC
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	8936357	OTHER	WA	CRIME VICTIMS

General Provider Information

NPI Number	:	1659363349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NANCY J RUSSELL MS, PT

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:	630-296-2223
Fax Number	:	630-759-9510

Provider Business Practice Location Address
First Line	:	10004 204TH AVE E
Second Line	:	STE 3100
City	:	BONNEY LAKE
State	:	WA
Zip	:	98391-6539
Country	:	US
Telephone Number	:	253-863-7510
Fax Number	:	253-863-5970

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

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	07/17/2015

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