Provider Demographics
NPI:1497033112
Name:RUSSELL, SHERRY LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:LYNN
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 318
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE
Mailing Address - State:OH
Mailing Address - Zip Code:45674-0318
Mailing Address - Country:US
Mailing Address - Phone:740-245-0033
Mailing Address - Fax:740-245-0031
Practice Address - Street 1:100 STATE ROUTE 325 SOUTH
Practice Address - Street 2:
Practice Address - City:RIO GRANDE
Practice Address - State:OH
Practice Address - Zip Code:45674-0318
Practice Address - Country:US
Practice Address - Phone:740-245-0033
Practice Address - Fax:740-245-0031
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.12484-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000440444OtherOH MEDICAID UNISON
WV3810021001Medicaid
OH0052337Medicaid
OH0200820Medicaid
OHH015190Medicare PIN