Provider Demographics
NPI:1205838661
Name:RUSSELL, TERRI LYNNE (RN MS CNS)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:LYNNE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RN MS CNS
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:LYNNE
Other - Last Name:FOWLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:540 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1601
Mailing Address - Country:US
Mailing Address - Phone:952-442-4437
Mailing Address - Fax:952-442-3084
Practice Address - Street 1:540 E 1ST ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1601
Practice Address - Country:US
Practice Address - Phone:952-442-4437
Practice Address - Fax:952-442-3084
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-122719-6163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP28174OtherHEALTH PARTNERS
MN123169OtherU-CARE
MN1023258OtherPREFERRED ONE
MN07F62RUOtherBLUE CROSS BLUE SHIELD
MN6249427OtherUBH-MEDICA