Provider Demographics
NPI:1942484308
Name:RUSSELL-WILSON, CHRISSIE COLLETTE (ARNP)
Entity Type:Individual
Prefix:
First Name:CHRISSIE
Middle Name:COLLETTE
Last Name:RUSSELL-WILSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:CHRISSIE
Other - Middle Name:COLLETTE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4825
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4825
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:360-604-1771
Practice Address - Street 1:501 SE 172ND AVE STE 130
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1772
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007938363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1079961Medicaid
WAG8882087Medicare PIN