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Individual

MARY THERESA RUSSELL

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
NP

Contact information

Practice address
3834 S EMERSON AVE STE 100, INDIANAPOLIS, IN 46203
(317) 782-1577
(317) 780-5549
Mailing address
PO BOX 3299, CARSON CITY, NV 89702-3299
(775) 222-0044
(888) 700-0187

Taxonomy

Speciality
Code
Description
License number
State
363LA2200X
Adult Health Nurse Practitioner
Primary
71002193A
IN

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
200492000
IN
Enumeration date
08/03/2006
Last updated
02/25/2020
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