Provider Demographics
NPI:1063819993
Name:RUSSELL, SHERRI CARLYLE (NP)
Entity type:Individual
Prefix:
First Name:SHERRI
Middle Name:CARLYLE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-2771
Mailing Address - Country:US
Mailing Address - Phone:812-231-8323
Mailing Address - Fax:
Practice Address - Street 1:622 8TH AVE
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-2744
Practice Address - Country:US
Practice Address - Phone:812-231-8377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28098686A363LA2200X
IN71005423A363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000933823OtherANTHEM
IN201285510Medicaid
IN201285510Medicaid