Provider Demographics
NPI:1225316722
Name:RUSSELL, ELISSA (APN, CNP)
Entity Type:Individual
Prefix:MRS
First Name:ELISSA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:APN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 78866
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8866
Mailing Address - Country:US
Mailing Address - Phone:779-696-7150
Mailing Address - Fax:779-696-7342
Practice Address - Street 1:1340 CHARLES ST
Practice Address - Street 2:SUITE 300
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104
Practice Address - Country:US
Practice Address - Phone:779-696-5888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008946363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400141741Medicare PIN