1679349765 NPI number — MISS ROSLYNN PERTRISE RUSSELL PT 34682

Table of content: MISS ROSLYNN PERTRISE RUSSELL PT 34682 (NPI 1679349765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679349765 NPI number — MISS ROSLYNN PERTRISE RUSSELL PT 34682

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
ROSLYNN
Provider Middle Name:
PERTRISE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PT 34682
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679349765
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3433 W SHAW AVE STE 108
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93711-3229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-558-4051
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
496 S BARTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93702-2985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-860-4422
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/29/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 167G00000X , with the licence number:  34682 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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