Provider Demographics
NPI:1124153457
Name:RUSSELL, DEBORAH M (LMP, RN)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2869
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-2869
Mailing Address - Country:US
Mailing Address - Phone:509-989-0875
Mailing Address - Fax:
Practice Address - Street 1:705 E HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1425
Practice Address - Country:US
Practice Address - Phone:509-989-0875
Practice Address - Fax:509-488-7224
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015323225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist