Provider Demographics
NPI:1144752437
Name:RUSSELL, LATRICIA (NP-C)
Entity Type:Individual
Prefix:
First Name:LATRICIA
Middle Name:
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 1:2510 SHADOW OAKS DR
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-6070
Mailing Address - Country:US
Mailing Address - Phone:713-594-9669
Mailing Address - Fax:
Practice Address - Street 1:2510 SHADOW OAKS DR
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:TX
Practice Address - Zip Code:77545-6070
Practice Address - Country:US
Practice Address - Phone:713-594-9669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP133485363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care