Provider Demographics
NPI:1255304440
Name:RUSSELL, DEBRA G (FNP)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:G
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-0699
Mailing Address - Country:US
Mailing Address - Phone:573-686-4750
Mailing Address - Fax:573-686-4753
Practice Address - Street 1:225 PHYSICIANS PARK STE 203
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3921
Practice Address - Country:US
Practice Address - Phone:573-686-4750
Practice Address - Fax:573-686-4753
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO076908363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO425335809Medicaid
MOMA1428006Medicare PIN
MO425335809Medicaid