Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225700000X | Massage Therapist | 35 | MS |
NPI | 1013303296 |
---|---|
Provider Name | Charlene Russell |
First Address | Vancleave, MS 39565-5667 |
Second Address | Vancleave, MS 39565-7420 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/04/2015 |
Last Update Date | 14/04/2015 |