Provider Demographics
NPI:1497734727
Name:RUSSELL, LAURALEI S (MSN, APRN, BC)
Entity Type:Individual
Prefix:
First Name:LAURALEI
Middle Name:S
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MSN, APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-1605
Mailing Address - Country:US
Mailing Address - Phone:731-588-5829
Mailing Address - Fax:731-587-8810
Practice Address - Street 1:920 UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-1605
Practice Address - Country:US
Practice Address - Phone:731-588-5829
Practice Address - Fax:731-587-8810
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN98960363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3901296Medicaid
TNP00095364OtherRAILROAD MEDICARE
TN4100240OtherBCBS OF TN MPAC
TN4083487OtherBCBS OF TN SYMED
TN3901295Medicaid
TN3901296Medicaid
TN4100240OtherBCBS OF TN MPAC