Individual
CONNIE RUSSELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1205 E BONNER WAY, SALT LAKE CITY, UT 84117-4917
(801) 598-8337
Mailing address
9091 S EXCALIBER WAY, WEST JORDAN, UT 84088-6583
(801) 824-7406
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
366691-3102
UT
363LF0000X
Family Nurse Practitioner
Primary
366691-4405
UT
Other
Enumeration date
10/09/2019
Last updated
10/15/2020
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