Provider Demographics
NPI:1659435915
Name:RUSSELL, MARY CATHERINE (FNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CATHERINE
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 1:2233 NE 41ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-5412
Mailing Address - Country:US
Mailing Address - Phone:503-220-8262
Mailing Address - Fax:503-721-1070
Practice Address - Street 1:3710 SW US VETERANS HOSP RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97207
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:503-721-1070
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20050116363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily