Provider Demographics
NPI:1265998744
Name:RUSSELL, MEDINA Y
Entity type:Individual
Prefix:
First Name:MEDINA
Middle Name:Y
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MEDINA
Other - Middle Name:Y
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:604 FALL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:MO
Mailing Address - Zip Code:64012-7814
Mailing Address - Country:US
Mailing Address - Phone:480-387-8096
Mailing Address - Fax:
Practice Address - Street 1:604 FALL CREEK DR
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:MO
Practice Address - Zip Code:64012-7814
Practice Address - Country:US
Practice Address - Phone:480-387-8096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health