Provider Demographics
NPI:1194283721
Name:RUSSELL, GREGORY (APRN)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 CAMIN LN
Mailing Address - Street 2:
Mailing Address - City:WALTON
Mailing Address - State:KY
Mailing Address - Zip Code:41094-7506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:859-743-1083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-02
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.365577163WF0300X
OHAPRN.CNP.025098363LA2100X
OH025098363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WF0300XNursing Service ProvidersRegistered NurseFlight
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care