Individual
THERESA A RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP
Contact information
Practice address
406 NE 1ST ST, ENTERPRISE, OR 97828-1168
(541) 426-4502
(541) 426-6403
Mailing address
406 NE 1ST ST, ENTERPRISE, OR 97828-1168
(541) 426-4502
(541) 426-6403
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
91000286
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
276716
—
OR
01
—
500008058
MEDICARE RAILROAD
OR
01
—
5966011
BCBS
OR
01
—
J054905
PACIFIC SOURCE
OR
Enumeration date
08/23/2005
Last updated
12/13/2013
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