Provider Demographics
NPI:1205314622
Name:RUSSELL, PAIGE TARA (DNP, NP-C)
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:TARA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DNP, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1343
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-0863
Mailing Address - Country:US
Mailing Address - Phone:208-255-9005
Mailing Address - Fax:208-263-2033
Practice Address - Street 1:423 N 3RD AVE STE 210
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1511
Practice Address - Country:US
Practice Address - Phone:208-263-6876
Practice Address - Fax:208-263-2033
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID59352363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily