Basic Information
| Provider Information | |||||||||
| NPI: | 1972696631 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | M . | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3360 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663662983 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 916 PACIFIC AVE 2ND FLOOR | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253036500 | ||||||||
| FaxNumber: | 4253036550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 02/17/2015 | ||||||||
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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 | 176B00000X | AP30005799 | WA | Y | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | 9630906 | 05 | WA | MEDICAID | AB24828 | 01 | WA | MEDICARE | OTHER |