Fawn Russell

Primary specialty

Speech-Language PathologistTaxonomy code 235Z00000X

License

146.015288 Issued in IL

Practice address

490 Avenue of the Cities
East Moline, IL 61244-4031

Phone

(309) 796-1251

NPI assigned

May 11, 2018

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1525996800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1609372800000",
    "number": "1326538638",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 6255",
            "city": "ROCK ISLAND",
            "state": "IL",
            "postal_code": "612046255",
            "telephone_number": "414-429-3332",
            "fax_number": "309-743-2073"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "490 AVENUE OF THE CITIES",
            "city": "EAST MOLINE",
            "state": "IL",
            "postal_code": "612444031",
            "telephone_number": "309-796-1251"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2109 Cedarwood Dr Ste 200",
            "address_purpose": "LOCATION",
            "city": "Muscatine",
            "state": "IA",
            "postal_code": "527612670",
            "country_code": "US",
            "telephone_number": "563-288-6787",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "RUSSELL",
        "first_name": "FAWN",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2018-05-11",
        "last_updated": "2020-12-31",
        "certification_date": "2020-12-31",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "IA",
            "license": "091685",
            "primary": false
        },
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "IL",
            "license": "146.015288",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Speech-Language Pathologist in East Moline, IL
• Providers in East Moline, IL by specialty
• Speech-Language Pathologist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 31, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.