Provider Demographics
NPI:1053131060
Name:RUSSELL, MARIA JEANETTE
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:JEANETTE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:JEANETTE
Other - Last Name:FRIDENMAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1210 N SPRINGBROOK RD # B309
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-2092
Mailing Address - Country:US
Mailing Address - Phone:425-387-9416
Mailing Address - Fax:
Practice Address - Street 1:414 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-2697
Practice Address - Country:US
Practice Address - Phone:503-554-2521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program