Provider Demographics
NPI:1134671126
Name:RUSSELL, SANDRA ALLISON (NP-C)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:ALLISON
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 J H PHILLIPS LN
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-7012
Mailing Address - Country:US
Mailing Address - Phone:662-539-0233
Mailing Address - Fax:662-539-6115
Practice Address - Street 1:303 J H PHILLIPS LN
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-7012
Practice Address - Country:US
Practice Address - Phone:662-539-0233
Practice Address - Fax:662-539-6115
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAG0916010364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health