Provider Demographics
NPI:1417518747
Name:RUSSELL, MARY EILEEN KUMAH (ACNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:EILEEN KUMAH
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:ACNP
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 33269
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85067-3269
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:625 N 6TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-2155
Practice Address - Country:US
Practice Address - Phone:602-406-8222
Practice Address - Fax:602-406-7811
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-26
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ228209363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology