Provider Demographics
NPI:1972891885
Name:RUSSELL, LAURA KATHRYN (CRNA)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:KATHRYN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4036 N WALNUT GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-2210
Mailing Address - Country:US
Mailing Address - Phone:901-634-5003
Mailing Address - Fax:
Practice Address - Street 1:6060 PRIMACY PKWY STE 241
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5743
Practice Address - Country:US
Practice Address - Phone:901-725-5846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16735367500000X
TN23477146L00000X
TN135778163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No163W00000XNursing Service ProvidersRegistered Nurse