Provider Demographics
NPI:1083627491
Name:RUSSART, JEANNE MARIE (LPN)
Entity type:Individual
Prefix:MRS
First Name:JEANNE
Middle Name:MARIE
Last Name:RUSSART
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N1495 WILLOW LANE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSPORT
Mailing Address - State:WI
Mailing Address - Zip Code:53010
Mailing Address - Country:US
Mailing Address - Phone:920-533-4676
Mailing Address - Fax:
Practice Address - Street 1:N1495 WILLOW LANE
Practice Address - Street 2:JEANNE RUSSART
Practice Address - City:CAMPBELLSPORT
Practice Address - State:WI
Practice Address - Zip Code:53010
Practice Address - Country:US
Practice Address - Phone:920-533-4676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31627031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39893600Medicaid