Provider Demographics
NPI:1639611767
Name:SMITH, RUSSELL (RN, FNP)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 LIZBEC CT
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-3246
Mailing Address - Country:US
Mailing Address - Phone:301-801-6725
Mailing Address - Fax:
Practice Address - Street 1:1230 BAY DALE DR
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MD
Practice Address - Zip Code:21012-2325
Practice Address - Country:US
Practice Address - Phone:410-757-0027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR182595363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily