Provider Demographics
NPI:1932219581
Name:RUSSELL, SANDRA G (FNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:G
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-583-1559
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:15 PUMPING STATION RD
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-8325
Practice Address - Country:US
Practice Address - Phone:601-583-1559
Practice Address - Fax:601-583-1573
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR639834363L00000X
MS639834363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1501891Medicaid
MS640507572KLOtherAMERICAN ADMIN GROUP
MS00117682Medicaid
MS640507572KLOtherAMERICAN ADMIN GROUP
MS640507572KLOtherAMERICAN ADMIN GROUP
MS500002196OtherRAILROAD MEDICARE