Basic Information
| Provider Information | |||||||||
| NPI: | 1225024839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 54 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650653050 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 304 A EAST 4TH ST | ||||||||
| Address2: | |||||||||
| City: | ELDON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733925654 | ||||||||
| FaxNumber: | 5733925692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 05/05/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 108385 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 425198603 | 05 | MO | MEDICAID | P00030899 | 01 | MO | RAILROAD MEDICARE | OTHER |