Provider Demographics
NPI:1629349303
Name:RUSSELL, SANDRA L (FNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
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 1:2150 W. 18TH STREET
Mailing Address - Street 2:#300
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008
Mailing Address - Country:US
Mailing Address - Phone:713-426-0027
Mailing Address - Fax:713-526-1422
Practice Address - Street 1:17010 SUGAR PINE DR.
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090
Practice Address - Country:US
Practice Address - Phone:281-537-8627
Practice Address - Fax:281-537-8628
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX513234363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX202850801Medicaid
TX671910Medicare PIN