Provider Demographics
NPI:1205308640
Name:RUSSELL, JOHANNA MERCEDEZ (APRN)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:MERCEDEZ
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN-BC
Mailing Address - Street 1:425 N LEE ST STE 104
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-1128
Mailing Address - Country:US
Mailing Address - Phone:904-427-1250
Mailing Address - Fax:
Practice Address - Street 1:425 N LEE ST STE 104
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-1128
Practice Address - Country:US
Practice Address - Phone:904-427-1250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-26
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11001221363LF0000X, 363LA2200X
FL9309493363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty