Provider Demographics
NPI:1962749069
Name:RUSSELL, KAREN M
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:M
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 1:433 W DONALD ST
Mailing Address - Street 2:APARTMENT 101
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-1245
Mailing Address - Country:US
Mailing Address - Phone:318-359-2793
Mailing Address - Fax:
Practice Address - Street 1:433 W DONALD ST
Practice Address - Street 2:APARTMENT 101
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1245
Practice Address - Country:US
Practice Address - Phone:318-359-2793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAX000105546OtherIOWA MEDICAID ENTERPRISE