Individual
JOHN MICHAEL RUSSELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PMHNP
Contact information
Practice address
12732 SE STARK ST, PORTLAND, OR 97233-1539
(503) 514-1264
Mailing address
12732 SE STARK ST, PORTLAND, OR 97233-1539
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
—
OR
Other
Enumeration date
08/04/2006
Last updated
07/26/2007
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