Provider Demographics
NPI:1760223374
Name:RUSSELL, HOLLY (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 74TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-7287
Mailing Address - Country:US
Mailing Address - Phone:541-868-7015
Mailing Address - Fax:
Practice Address - Street 1:890 BELTLINE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-1091
Practice Address - Country:US
Practice Address - Phone:541-868-7015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200841838RN163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant