Provider Demographics
NPI:1124346077
Name:RUSSELL, MARIE ELLEN (LPN)
Entity type:Individual
Prefix:MS
First Name:MARIE
Middle Name:ELLEN
Last Name:RUSSELL
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 1:165 SUNSET LN
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45786-6337
Mailing Address - Country:US
Mailing Address - Phone:740-984-8061
Mailing Address - Fax:
Practice Address - Street 1:165 SUNSET LN
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:OH
Practice Address - Zip Code:45786-6337
Practice Address - Country:US
Practice Address - Phone:740-984-8061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-16
Last Update Date:2010-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN126486164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse