Provider Demographics
NPI:1992171391
Name:RUSSELL, KATELYNN CHRISTINE
Entity type:Individual
Prefix:
First Name:KATELYNN
Middle Name:CHRISTINE
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 1:127 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-4700
Mailing Address - Country:US
Mailing Address - Phone:580-931-3008
Mailing Address - Fax:580-931-2008
Practice Address - Street 1:127 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-4700
Practice Address - Country:US
Practice Address - Phone:580-931-3008
Practice Address - Fax:580-931-2008
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health