Provider Demographics
NPI:1770639346
Name:RUSSELL, TERESA M (NP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3485 OLD COBBLE CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-4045
Mailing Address - Country:US
Mailing Address - Phone:619-532-6950
Mailing Address - Fax:619-532-5501
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-532-6950
Practice Address - Fax:619-532-5501
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA14528363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA504376OtherREGISTERED NURSE
CA0387014-21OtherNURSE PRACTITIONER CRED
CA199934486OtherCERT. WOUND OSTOMY CARE