Provider Demographics
NPI:1114571429
Name:RUSSELL, LORA A (APRN)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:A
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 1:36 PEMBERTON CV
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-5514
Mailing Address - Country:US
Mailing Address - Phone:731-394-1145
Mailing Address - Fax:844-374-0233
Practice Address - Street 1:419 N SEMINARY ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1515
Practice Address - Country:US
Practice Address - Phone:731-394-1145
Practice Address - Fax:844-374-0233
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012804363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily