Provider Demographics
NPI:1215319488
Name:RUSSELL, HOLLY (LPN)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
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 1:11009 LOUIS DR SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35803-1007
Mailing Address - Country:US
Mailing Address - Phone:256-650-3174
Mailing Address - Fax:
Practice Address - Street 1:11009 LOUIS DR SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35803-1007
Practice Address - Country:US
Practice Address - Phone:256-650-3174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2-058533164W00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No164W00000XNursing Service ProvidersLicensed Practical Nurse