Provider Demographics
NPI:1316337694
Name:RUSSELL, KEASHA (ATC)
Entity type:Individual
Prefix:MISS
First Name:KEASHA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12648 MEMORIAL WAY
Mailing Address - Street 2:2075
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-7553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3401 MUSTANG WAY
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-9257
Practice Address - Country:US
Practice Address - Phone:951-760-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000030642255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer