Provider Demographics
NPI:1932524261
Name:RUSSELL, KARAN DAWN (APRN)
Entity Type:Individual
Prefix:
First Name:KARAN
Middle Name:DAWN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SE 2ND ST
Mailing Address - Street 2:STE 100
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-2759
Mailing Address - Country:US
Mailing Address - Phone:419-251-9830
Mailing Address - Fax:419-251-1826
Practice Address - Street 1:1532 LONE OAK RD STE 345
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7942
Practice Address - Country:US
Practice Address - Phone:270-444-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-24
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS77671163W00000X
KY3011211363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100484040Medicaid