Provider Demographics
NPI:1063263416
Name:RUSSELL, SHAWNTERRA MARIE
Entity type:Individual
Prefix:
First Name:SHAWNTERRA
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12608 GRIMSBY AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44135-4850
Mailing Address - Country:US
Mailing Address - Phone:216-780-0251
Mailing Address - Fax:
Practice Address - Street 1:12608 GRIMSBY AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44135-4850
Practice Address - Country:US
Practice Address - Phone:330-490-9395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.006787175T00000X
372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty