Provider Demographics
NPI:1225452600
Name:RUSSELL, TANYA (FNP)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 MARSHA SHARP FWY
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-2520
Mailing Address - Country:US
Mailing Address - Phone:806-744-7223
Mailing Address - Fax:806-740-3325
Practice Address - Street 1:4515 MARSHA SHARP FWY
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407
Practice Address - Country:US
Practice Address - Phone:806-744-7223
Practice Address - Fax:806-740-3325
Is Sole Proprietor?:No
Enumeration Date:2014-02-06
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX735250363LP0200X
TXAP122632363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics