Provider Demographics
NPI:1548758543
Name:RUSSELL, MELINDA ROCHELLE (NP)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:ROCHELLE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18701 BRETTON DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-1379
Mailing Address - Country:US
Mailing Address - Phone:313-703-9710
Mailing Address - Fax:
Practice Address - Street 1:23999 NORTHWESTERN HWY STE 114
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2578
Practice Address - Country:US
Practice Address - Phone:248-278-8937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704266784363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704266784OtherNURSE PRACTITIONER