Provider Demographics
NPI:1679558076
Name:RUSSELL, MARIA RAE (TECHNICIAN)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:RAE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 KIRKLAND AVE NE
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-3217
Mailing Address - Country:US
Mailing Address - Phone:425-277-8017
Mailing Address - Fax:
Practice Address - Street 1:6939 COAL CREEK PKWY SE
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:WA
Practice Address - Zip Code:98059-3136
Practice Address - Country:US
Practice Address - Phone:425-644-4416
Practice Address - Fax:425-644-7427
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA00022299183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician