Individual
CONNIE RUSSELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
502 S CHOCTAW AVE, WAPANUCKA, OK 73461-9235
(580) 937-4288
(580) 937-4804
Mailing address
502 S CHOCTAW AVE, WAPANUCKA, OK 73461-9235
(580) 937-4288
(580) 937-4804
Taxonomy
Speciality
Code
Description
License number
State
251K00000X
Public Health or Welfare Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100687480A
—
OK
Enumeration date
03/01/2016
Last updated
03/01/2016
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