Provider Demographics
NPI:1811347586
Name:RUSSELL, JAMIE LYNN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1712 S STRATFORD RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2926
Practice Address - Country:US
Practice Address - Phone:336-718-4995
Practice Address - Fax:336-718-4999
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC5008756363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner