Provider Demographics
NPI:1578015137
Name:RUSSELL, JAMIE (APRN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 STOUT DRIVE, BOX 70403
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37614-1703
Mailing Address - Country:US
Mailing Address - Phone:423-439-4515
Mailing Address - Fax:423-439-5780
Practice Address - Street 1:365 STOUT DRIVE, SUITE 160
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37614-1703
Practice Address - Country:US
Practice Address - Phone:423-439-4225
Practice Address - Fax:423-439-4560
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21637363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN21637OtherLICENSE