Provider Demographics
NPI:1477124626
Name:RUSSELL, LAURA JANELLE (LVN)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JANELLE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:MRS
Other - First Name:LAURA
Other - Middle Name:JANELLE
Other - Last Name:BLICKENSTAFF-RUSSELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LVN
Mailing Address - Street 1:3055 W ORANGE AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3152
Mailing Address - Country:US
Mailing Address - Phone:714-638-8277
Mailing Address - Fax:714-638-8343
Practice Address - Street 1:3055 W ORANGE AVE STE 105
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3152
Practice Address - Country:US
Practice Address - Phone:714-638-8277
Practice Address - Fax:714-638-8343
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN165899164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse