Provider Demographics
NPI:1437572344
Name:RUSSELL, PERRY (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:PERRY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 HIGHWAY 22 W
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-9441
Mailing Address - Country:US
Mailing Address - Phone:985-773-1600
Mailing Address - Fax:
Practice Address - Street 1:1520 HIGHWAY 22 W
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70447
Practice Address - Country:US
Practice Address - Phone:985-773-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07653363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2381199Medicaid