Provider Demographics
NPI:1366903965
Name:RUSSELL, COURTNEY ANNE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ANNE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CASTLE
Other - Middle Name:
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:368 FELL ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-5144
Mailing Address - Country:US
Mailing Address - Phone:415-861-0828
Mailing Address - Fax:
Practice Address - Street 1:25 BEULAH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-3909
Practice Address - Country:US
Practice Address - Phone:415-861-0828
Practice Address - Fax:415-861-0140
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker