Provider Demographics
NPI:1790875425
Name:RUSSELL, NANCY KAE (MD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:KAE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NANCY
Other - Middle Name:K
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5140 NE ANTIOCH RD
Mailing Address - Street 2:NURTURING OPTIMAL WELLNESS
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64119-2523
Mailing Address - Country:US
Mailing Address - Phone:816-453-5545
Mailing Address - Fax:800-261-2718
Practice Address - Street 1:5140 NE ANTIOCH RD
Practice Address - Street 2:NURTURING OPTIMAL WELLNESS
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64119-2523
Practice Address - Country:US
Practice Address - Phone:816-453-5545
Practice Address - Fax:800-261-2718
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36094207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO12799020OtherNON-PROVIDER # BCBS
KS68517OtherNON-PROVIDER # BCBS KS
KS68517OtherNON-PROVIDER # BCBS KS
MO431365020OtherFEDERAL TAX ID #