Provider Demographics
NPI:1114699923
Name:RUSSELL, MELODY ANN (ACAGNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MELODY
Middle Name:ANN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:ACAGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 E PRIMROSE ST STE E
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5233
Mailing Address - Country:US
Mailing Address - Phone:417-553-1080
Mailing Address - Fax:888-472-5145
Practice Address - Street 1:222 E PRIMROSE ST STE E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5233
Practice Address - Country:US
Practice Address - Phone:417-553-1080
Practice Address - Fax:888-472-5145
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020040257363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420118182Medicaid