Provider Demographics
NPI:1265748826
Name:RUSSELL, PATRICIA LYNN (ARNP)
Entity type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:6500 UNIVERSITY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50324-1607
Practice Address - Country:US
Practice Address - Phone:515-279-1959
Practice Address - Fax:515-289-0888
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-20
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-102064363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1457304446Medicaid
IAP01016712OtherRR MEDICARE
IA1457304446OtherWELLMARK BCBS
IAI-43700003Medicare PIN