Provider Demographics
NPI:1194311522
Name:RUSSELL, TAMMY WATSON
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:WATSON
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 1:654 CORBEL DR
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-7096
Mailing Address - Country:US
Mailing Address - Phone:614-749-2189
Mailing Address - Fax:
Practice Address - Street 1:969 W 5TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-1070
Practice Address - Country:US
Practice Address - Phone:937-644-3615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-20
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH474767163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse