Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 176B00000X | Midwife | MW333 | FL |
NPI | 1154774651 |
---|---|
Provider Name | Lisa Russell |
First Address | Sarasota, FL 34232-5027 |
Second Address | Sarasota, FL 34232-5027 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2016 |
Last Update Date | 20/07/2016 |