Provider Demographics
NPI:1275631863
Name:RUSSELL, KATHLEEN A (NP)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:A
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:KATHLEEN
Other - Middle Name:A
Other - Last Name:MCCLAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:445 CENTENNIAL AVE
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-2870
Mailing Address - Country:US
Mailing Address - Phone:406-723-4075
Mailing Address - Fax:406-496-6035
Practice Address - Street 1:110 OAK ST
Practice Address - Street 2:
Practice Address - City:ANACONDA
Practice Address - State:MT
Practice Address - Zip Code:59711-2335
Practice Address - Country:US
Practice Address - Phone:406-563-0071
Practice Address - Fax:406-563-0774
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN019215363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000370310OtherBCBS