Provider Demographics
NPI:1114755691
Name:RUSSELL, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name: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 1:949 WOODSIDE RD APT 20
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-4161
Mailing Address - Country:US
Mailing Address - Phone:616-223-8338
Mailing Address - Fax:
Practice Address - Street 1:949 WOODSIDE RD APT 20
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-4161
Practice Address - Country:US
Practice Address - Phone:616-223-8338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant