Provider Demographics
NPI:1154082170
Name:RUSSELL, COURTNEY (FNP-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13149 W CLIFFROSE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-2269
Mailing Address - Country:US
Mailing Address - Phone:623-512-3015
Mailing Address - Fax:
Practice Address - Street 1:5750 W THUNDERBIRD RD STE C300
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4666
Practice Address - Country:US
Practice Address - Phone:855-485-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-02
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZF12210398363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner