Provider Demographics
NPI:1649037904
Name:RUSSELL, SARAH (FNP-C)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2761 HIGHWAY 15
Mailing Address - Street 2:
Mailing Address - City:BAY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39422-7432
Mailing Address - Country:US
Mailing Address - Phone:601-764-2419
Mailing Address - Fax:
Practice Address - Street 1:2761 HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:BAY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39422-7432
Practice Address - Country:US
Practice Address - Phone:601-764-2419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS908687163WC0400X
MS906491363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WC0400XNursing Service ProvidersRegistered NurseCase Management