Provider Demographics
NPI:1255878740
Name:RUSSELL, SAMANTHA HEATHER
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:HEATHER
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 1:25055 W VALLEY PKWY STE 220
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-8450
Mailing Address - Country:US
Mailing Address - Phone:913-378-1061
Mailing Address - Fax:913-904-1399
Practice Address - Street 1:25055 W VALLEY PKWY STE 220
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-8450
Practice Address - Country:US
Practice Address - Phone:913-378-1061
Practice Address - Fax:913-904-1399
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5377031363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health