Provider Demographics
NPI:1679344089
Name:RUSSELL, CHASSIDY MERCEDES (MSN, APRN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:CHASSIDY
Middle Name:MERCEDES
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MSN, 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 1:4749 IRISH RED CT
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-3480
Mailing Address - Country:US
Mailing Address - Phone:229-942-5927
Mailing Address - Fax:
Practice Address - Street 1:334 NEWNAN CROSSING BYP
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1082
Practice Address - Country:US
Practice Address - Phone:470-524-2177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2023127904363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner