MEDICARE: KAITLIN MARIE RUSSELL CWC

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	171400000X	Health & Wellness Coach		CA

General Provider Information

NPI Number	:	1861362741
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLIN MARIE RUSSELL CWC

Provider Business Mailing Address
First Line	:	150 3RD ST
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94901-4126
Country	:	US
Telephone Number	:	415-485-2330
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 3RD ST
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94901-4126
Country	:	US
Telephone Number	:	415-485-2330
Fax Number	:

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

Provider Enumeration Date	:	11/06/2025
Last Update Date	:	11/06/2025

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