Provider Demographics
NPI:1245333046
Name:RUSSELL, RANA WYNNE (FNP)
Entity type:Individual
Prefix:
First Name:RANA
Middle Name:WYNNE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 IRISH RD
Mailing Address - Street 2:
Mailing Address - City:RANCHOS DE TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87557-8753
Mailing Address - Country:US
Mailing Address - Phone:830-660-2888
Mailing Address - Fax:
Practice Address - Street 1:528 N CORONADO AVE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2790
Practice Address - Country:US
Practice Address - Phone:505-747-6939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX579441363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147912305Medicaid
8N3798OtherBLUE CROSS/BLUE SHIELD
TX147912305Medicaid
P44393Medicare UPIN