Individual
EARL D RUSSELL JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
FNP
Contact information
Practice address
427 HIGHWAY 51 N, BROOKHAVEN, MS 39601-2350
(601) 823-5301
(601) 833-8742
Mailing address
PO BOX 5440, BROOKHAVEN, MS 39603-5440
(601) 587-7983
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
R852034
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
R852034
MS LICENSE
MS
Enumeration date
07/02/2008
Last updated
07/02/2008
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