Basic Information
| Provider Information | |||||||||
| NPI: | 1124167051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | AYANNA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7391 9TH ST APT 6 | ||||||||
| Address2: | |||||||||
| City: | BUENA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906212746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109467979 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3875 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900621105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232904356 | ||||||||
| FaxNumber: | 3232933327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | VN167101 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.