Provider Demographics
NPI:1073785408
Name:RUSSELL, GEORGIA (APRN)
Entity Type:Individual
Prefix:MRS
First Name:GEORGIA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 WILLIAMS WAY
Mailing Address - Street 2:
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-2185
Mailing Address - Country:US
Mailing Address - Phone:435-719-3510
Mailing Address - Fax:435-719-3509
Practice Address - Street 1:450 WILLIAMS WAY
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532
Practice Address - Country:US
Practice Address - Phone:435-719-3510
Practice Address - Fax:435-719-3509
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT209410-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily