Provider Demographics
NPI:1386781060
Name:RUSSELL, KIMBERLEY A (NP)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:A
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 1:100 SHATTUCK WAY
Mailing Address - Street 2:STE 100
Mailing Address - City:NEWINGTON
Mailing Address - State:NH
Mailing Address - Zip Code:03801-8007
Mailing Address - Country:US
Mailing Address - Phone:603-431-6677
Mailing Address - Fax:603-610-7713
Practice Address - Street 1:35 WALKER ST
Practice Address - Street 2:
Practice Address - City:KITTERY
Practice Address - State:ME
Practice Address - Zip Code:03904-1727
Practice Address - Country:US
Practice Address - Phone:207-439-4430
Practice Address - Fax:207-439-0968
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP081884363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME000693601Medicare PIN