Provider Demographics
NPI:1528714284
Name:RUSSELL, CARA (LPN)
Entity type:Individual
Prefix:
First Name:CARA
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 1:116 1/2 W LOCUST ST APT 3
Mailing Address - Street 2:
Mailing Address - City:FAIRBURY
Mailing Address - State:IL
Mailing Address - Zip Code:61739-1575
Mailing Address - Country:US
Mailing Address - Phone:309-262-6777
Mailing Address - Fax:
Practice Address - Street 1:303 LANDMARK DR STE 2B
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6164
Practice Address - Country:US
Practice Address - Phone:303-808-2388
Practice Address - Fax:309-808-2668
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043-081235164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse