Basic Information
| Provider Information | |||||||||
| NPI: | 1386200236 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | CIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 FM 300 | ||||||||
| Address2: | |||||||||
| City: | LEVELLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 793366235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8068947842 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 FM 300 | ||||||||
| Address2: | |||||||||
| City: | LEVELLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 793366235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8068947842 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2019 | ||||||||
| LastUpdateDate: | 09/25/2019 | ||||||||
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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 | 363LP0200X | AP140210 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | AP140210 | 01 | TX | TEXAS BOARD OF NURSING- PEDIATRIC NURSE PRACTITIONER LICENSURE | OTHER | 772532 | 01 | TX | TEXAS BOARD OF NURSING- RN LICENSURE | OTHER |