Provider Demographics
NPI:1902826993
Name:RUSSELL, ANGELA P
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:P
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 NW 12TH AVE
Mailing Address - Street 2:BOX 016960 M851
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1002
Mailing Address - Country:US
Mailing Address - Phone:305-243-7520
Mailing Address - Fax:
Practice Address - Street 1:1475 NW 12TH AVE
Practice Address - Street 2:BOX 016960 M851
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1002
Practice Address - Country:US
Practice Address - Phone:305-243-7520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1082342363L00000X
FL1082342363LP0808X
FL082342364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3050742-00Medicaid
FLP50704Medicare UPIN