Provider Demographics
NPI:1164589974
Name:RUSSELL KIBBLE, AUDREY (DNP, FNP-C)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:
Last Name:RUSSELL KIBBLE
Suffix:
Gender:F
Credentials:DNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 W SPEEDWAY BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-7698
Mailing Address - Country:US
Mailing Address - Phone:520-628-7871
Mailing Address - Fax:520-205-8461
Practice Address - Street 1:140 W SPEEDWAY BLVD
Practice Address - Street 2:STE 100
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-7698
Practice Address - Country:US
Practice Address - Phone:520-628-7871
Practice Address - Fax:520-205-8461
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN026677363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ557902Medicaid
AZ557902OtherPIMA HEALTH SYSTEMS
AZ557902001OtherMERCY CARE PLAN
AZ557902Medicaid
AZ107673Medicare ID - Type Unspecified