Provider Demographics
NPI:1063067098
Name:HENRY-RUSSELL, CORRETTA N
Entity type:Individual
Prefix:MRS
First Name:CORRETTA
Middle Name:N
Last Name:HENRY-RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1672 STARGAZER TER
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-9286
Mailing Address - Country:US
Mailing Address - Phone:407-860-8048
Mailing Address - Fax:
Practice Address - Street 1:1672 STARGAZER TER
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-9286
Practice Address - Country:US
Practice Address - Phone:407-860-8048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities