Provider Demographics
NPI:1679349765
Name:RUSSELL, ROSLYNN PERTRISE (PT 34682)
Entity type:Individual
Prefix:MISS
First Name:ROSLYNN
Middle Name:PERTRISE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PT 34682
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 W SHAW AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3229
Mailing Address - Country:US
Mailing Address - Phone:559-558-4051
Mailing Address - Fax:
Practice Address - Street 1:496 S BARTON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-2985
Practice Address - Country:US
Practice Address - Phone:559-860-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-29
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34682167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician