Provider Demographics
NPI:1508053240
Name:RUSSELL, VALERIE MARIE (ARNP)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 SAINT JAMES CT STE 1
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5352
Mailing Address - Country:US
Mailing Address - Phone:850-431-7021
Mailing Address - Fax:
Practice Address - Street 1:15 COUNCIL MOORE RD
Practice Address - Street 2:
Practice Address - City:CRAWFORDVILLE
Practice Address - State:FL
Practice Address - Zip Code:32327-3117
Practice Address - Country:US
Practice Address - Phone:850-926-7105
Practice Address - Fax:850-926-2034
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA172311363LF0000X
FL3115262363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003076700Medicaid
GA127469258CMedicaid
GA127469258DMedicaid
GA127469258FMedicaid
GA127469258EMedicaid
GA127469258BMedicaid
GA127469258GMedicaid
GA127469258AMedicaid
GA127469258DMedicaid
GA511I500033Medicare PIN
FL003076700Medicaid