Provider Demographics
NPI:1508860578
Name:RUSSELL, DOROTHEA D (RN, MS, CNP)
Entity Type:Individual
Prefix:
First Name:DOROTHEA
Middle Name:D
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RN, MS, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 CHICAGO AVE SOUTH
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1320
Mailing Address - Country:US
Mailing Address - Phone:612-879-1000
Mailing Address - Fax:612-879-9116
Practice Address - Street 1:2828 CHICAGO AVE SOUTH
Practice Address - Street 2:SUITE 200
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1320
Practice Address - Country:US
Practice Address - Phone:612-879-1000
Practice Address - Fax:612-879-9116
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR06116062084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN303664200Medicaid
D41087Medicare UPIN
MN303664200Medicaid