Provider Demographics
NPI:1306254214
Name:RUSS, CARRIE (ANP)
Entity type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:
Last Name:RUSS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 GASTON AVE STE 404
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1804
Mailing Address - Country:US
Mailing Address - Phone:469-820-5516
Mailing Address - Fax:
Practice Address - Street 1:3600 GASTON AVE STE 404
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1804
Practice Address - Country:US
Practice Address - Phone:694-820-5516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP134155363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health