Provider Demographics
NPI:1780625244
Name:RUSSELL, SHIRLEY LOUISE (ARNP)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:LOUISE
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 1:8711 PERIMETER PARK BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6388
Mailing Address - Country:US
Mailing Address - Phone:904-223-2330
Mailing Address - Fax:
Practice Address - Street 1:5915 NORMANDY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-6200
Practice Address - Country:US
Practice Address - Phone:904-378-0121
Practice Address - Fax:904-378-0122
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9229120363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU5287ZMedicare PIN
S61559Medicare UPIN