Provider Demographics
NPI:1972879898
Name:RUSSELL, VANDA MARION
Entity type:Individual
Prefix:
First Name:VANDA
Middle Name:MARION
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 1:5056 FESTIVAL BLVD APT A
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-7610
Mailing Address - Country:US
Mailing Address - Phone:360-734-7177
Mailing Address - Fax:
Practice Address - Street 1:855 AARON DR
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-9396
Practice Address - Country:US
Practice Address - Phone:360-354-4434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-25
Last Update Date:2012-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA908225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist