Individual
KELLY RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MSN,RN,FNP-BC
Contact information
Practice address
900 N LIBERTY ST STE 101, BOISE, ID 83704-8858
(208) 367-8787
Mailing address
PO BOX 190930, BOISE, ID 83719-0930
(208) 302-9342
(208) 367-5180
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
79075
ID
363LF0000X
Family Nurse Practitioner
Primary
79075
ID
363LF0000X
Family Nurse Practitioner
95008457
CA
Other
Enumeration date
02/18/2019
Last updated
06/29/2026
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