Provider Demographics
NPI:1144411026
Name:RUSSELL, JANIE CADDIS (FNP)
Entity Type:Individual
Prefix:
First Name:JANIE
Middle Name:CADDIS
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CUT OFF RD
Mailing Address - Street 2:SUITE 14
Mailing Address - City:PORT ARANSAS
Mailing Address - State:TX
Mailing Address - Zip Code:78373-4246
Mailing Address - Country:US
Mailing Address - Phone:361-749-1930
Mailing Address - Fax:
Practice Address - Street 1:600 CUT OFF RD
Practice Address - Street 2:SUITE 14
Practice Address - City:PORT ARANSAS
Practice Address - State:TX
Practice Address - Zip Code:78373-4245
Practice Address - Country:US
Practice Address - Phone:361-749-1930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332820-1363LF0000X
TX512126363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily