Individual
SANDRA G RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP
Contact information
Practice address
15 PUMPING STATION RD, PETAL, MS 39465-8325
(601) 583-1559
(601) 583-1573
Mailing address
415 S 28TH AVE, HATTIESBURG, MS 39401-7246
(601) 583-1559
(601) 579-5240
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
R639834
MS
363LF0000X
Family Nurse Practitioner
Primary
639834
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00117682
—
MS
05
—
1501891
—
LA
01
—
640507572KL
AMERICAN ADMIN GROUP
MS
Enumeration date
08/30/2006
Last updated
07/20/2020
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