Provider Demographics
NPI:1225024839
Name:RUSSELL, JULIE L (NP)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:L
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:304 A EAST 4TH ST
Practice Address - Street 2:
Practice Address - City:ELDON
Practice Address - State:MO
Practice Address - Zip Code:65026
Practice Address - Country:US
Practice Address - Phone:573-392-5654
Practice Address - Fax:573-392-5692
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108385363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO425198603Medicaid
MOP00030899OtherRAILROAD MEDICARE
MOP00030899OtherRAILROAD MEDICARE
MO000081156Medicare PIN