Provider Demographics
NPI:1528268224
Name:RUSSELL, J COLLEEN (CPNP, APRN)
Entity type:Individual
Prefix:
First Name:J COLLEEN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CPNP, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:KY
Mailing Address - Zip Code:42220-9229
Mailing Address - Country:US
Mailing Address - Phone:270-265-5353
Mailing Address - Fax:270-265-5350
Practice Address - Street 1:713 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:KY
Practice Address - Zip Code:42220-9229
Practice Address - Country:US
Practice Address - Phone:270-265-5353
Practice Address - Fax:270-265-5350
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3040P364SP0200X
KY3003040363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYMR2865939OtherDEA