Provider Demographics
NPI:1235400532
Name:RUSSELL, MANDY R (MSN, APRN, NP-C)
Entity Type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:R
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MSN, APRN, NP-C
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 655
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:TN
Mailing Address - Zip Code:38372-0655
Mailing Address - Country:US
Mailing Address - Phone:731-925-2300
Mailing Address - Fax:731-925-3506
Practice Address - Street 1:726 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ADAMSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38310-2458
Practice Address - Country:US
Practice Address - Phone:731-925-2300
Practice Address - Fax:731-925-3506
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16444363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily