Provider Demographics
NPI:1982017968
Name:RUSSELL, NICOLE ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ELIZABETH
Other - Last Name:BIERIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:810 NORTH 6TH AVE.
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864
Mailing Address - Country:US
Mailing Address - Phone:208-265-6252
Mailing Address - Fax:
Practice Address - Street 1:810 NORTH 6TH AVE.
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864
Practice Address - Country:US
Practice Address - Phone:208-265-6252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-58693207Q00000X
390200000X
IDM-16119207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program