Basic Information
| Provider Information | |||||||||
| NPI: | 1861980435 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | STEVNIKA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10929 S KEATING AVE APT 3N | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604536262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128608459 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5517 N KENMORE AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606401515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732757962 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2018 | ||||||||
| LastUpdateDate: | 04/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 043-104842 | IL | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.