Provider Demographics
NPI:1760192462
Name:RUSSELL, PORCHE (APRN)
Entity Type:Individual
Prefix:
First Name:PORCHE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 BELLE RIVA DR
Mailing Address - Street 2:
Mailing Address - City:HALLSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75650-6133
Mailing Address - Country:US
Mailing Address - Phone:903-930-1034
Mailing Address - Fax:
Practice Address - Street 1:159 BELLE RIVA DR
Practice Address - Street 2:
Practice Address - City:HALLSVILLE
Practice Address - State:TX
Practice Address - Zip Code:75650-6133
Practice Address - Country:US
Practice Address - Phone:903-930-1034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1099955363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily