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NPI Code Detail

MEDICARE: LISA RUSSELL CRNA

MEDICARE: LISA RUSSELL CRNA
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
1367500000XCertified Registered Nurse AnesthetistIL

General Provider Information

NPI Number : 1881672582
Entity Type Code : Individual
Provider Name (Legal Business Name) : LISA RUSSELL CRNA
Provider Business Mailing Address
First Line : 2200 FORT JESSE RD
Second Line : SUITE 240
City : NORMAL
State : IL
Zip : 61761-6286
Country : US
Telephone Number : 309-268-9300
Fax Number : 309-268-0575
Provider Business Practice Location Address
First Line : 2200 FORT JESSE RD
Second Line : SUITE 240
City : NORMAL
State : IL
Zip : 61761-6286
Country : US
Telephone Number : 309-268-9300
Fax Number : 309-268-0575
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/04/2006
Last Update Date : 07/08/2007

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Directions to “ LISA RUSSELL CRNA” Practice Location

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