Provider Demographics
NPI:1285968461
Name:TERRELL-RUSS, IYAKU (FNP-C)
Entity type:Individual
Prefix:
First Name:IYAKU
Middle Name:
Last Name:TERRELL-RUSS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4687 N 68TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-4825
Mailing Address - Country:US
Mailing Address - Phone:414-699-9034
Mailing Address - Fax:
Practice Address - Street 1:4687 N 68TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-4825
Practice Address - Country:US
Practice Address - Phone:414-699-9034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-22
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7470-33363LF0000X
WI165570-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse