Individual
DATAVIA RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LPN
Contact information
Practice address
821 N EUTAW ST, BALTIMORE, MD 21201-4648
(410) 225-9185
Mailing address
3913 NORFOLK AVE, BALTIMORE, MD 21216-1240
(443) 413-8732
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
LP56057
MD
Other
Enumeration date
08/31/2023
Last updated
08/31/2023
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