Provider Demographics
NPI:1629061981
Name:RUSSELL, THERESA A (FNP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 NE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-1168
Mailing Address - Country:US
Mailing Address - Phone:541-426-4502
Mailing Address - Fax:541-426-6403
Practice Address - Street 1:406 NE 1ST ST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828-1168
Practice Address - Country:US
Practice Address - Phone:541-426-4502
Practice Address - Fax:541-426-6403
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR91000286363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5966011OtherBCBS
ORJ054905OtherPACIFIC SOURCE
OR276716Medicaid
OR500008058OtherMEDICARE RAILROAD
ORJ054905OtherPACIFIC SOURCE
OR500008058OtherMEDICARE RAILROAD
ORS85870Medicare UPIN