Provider Demographics
NPI:1992070825
Name:RUSSELL, MORLYN (FNPC, BSN, RN)
Entity type:Individual
Prefix:MS
First Name:MORLYN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:FNPC, BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:TOUGALOO
Mailing Address - State:MS
Mailing Address - Zip Code:39174-9700
Mailing Address - Country:US
Mailing Address - Phone:601-957-6776
Mailing Address - Fax:601-957-8840
Practice Address - Street 1:500 W COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:TOUGALOO
Practice Address - State:MS
Practice Address - Zip Code:39174-9700
Practice Address - Country:US
Practice Address - Phone:601-957-6776
Practice Address - Fax:601-957-8840
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-10
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR866907363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily