Provider Demographics
NPI:1235997768
Name:RUSSELL, AYANA D (NP-C)
Entity Type:Individual
Prefix:
First Name:AYANA
Middle Name:D
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6402 TITANIA DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-7707
Mailing Address - Country:US
Mailing Address - Phone:317-748-1373
Mailing Address - Fax:
Practice Address - Street 1:720 ESKENAZI AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5187
Practice Address - Country:US
Practice Address - Phone:317-880-3684
Practice Address - Fax:317-880-0532
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28254431A163W00000X
IN71015127A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71015127AOtherINDIANA PROFESSIONAL LICENSING AGENCY