Individual
JOHN RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1340 CHARLES ST, SUITE 300, ROCKFORD, IL 61104
(779) 696-8800
Mailing address
PO BOX 78866, MILWAUKEE, WI 53278-8866
(779) 696-7150
(779) 696-7342
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
041.368559
IL
363L00000X
Nurse Practitioner
209-011657
IL
363L00000X
Nurse Practitioner
Primary
277-000310
IL
Other
Enumeration date
05/13/2014
Last updated
11/26/2021
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