Provider Demographics
NPI:1518904663
Name:RUSSELL, CYNTHIA J (ARNP)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:J
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:J
Other - Last Name:FANTONI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN
Mailing Address - Street 1:2109 OAKFORD CT
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-7541
Mailing Address - Country:US
Mailing Address - Phone:502-225-0709
Mailing Address - Fax:
Practice Address - Street 1:920 DUPONT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4692
Practice Address - Country:US
Practice Address - Phone:502-895-2334
Practice Address - Fax:502-896-6987
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3654P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYQ59838Medicare UPIN
KY0927134Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID#