Provider Demographics
NPI:1154454155
Name:RUSSELL, MARIE (RN, MN, C-ANP)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RN, MN, C-ANP
Other - Prefix:
Other - First Name:MARI
Other - Middle Name:
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:6620 ANTIGUA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-4011
Mailing Address - Country:US
Mailing Address - Phone:848-384-7213
Mailing Address - Fax:
Practice Address - Street 1:7944 BIRMINGHAM DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2705
Practice Address - Country:US
Practice Address - Phone:858-939-4622
Practice Address - Fax:858-939-4627
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC188476363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health