Basic Information
Provider Information | |||||||||
NPI: | 1497732549 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUSSELL | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: | E. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 21975 | ||||||||
Address2: |   | ||||||||
City: | BELFAST | ||||||||
State: | ME | ||||||||
PostalCode: | 049154116 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403214281 | ||||||||
FaxNumber: | 5403214282 | ||||||||
Practice Location | |||||||||
Address1: | 541 SUNSET LN STE 301 | ||||||||
Address2: |   | ||||||||
City: | CULPEPER | ||||||||
State: | VA | ||||||||
PostalCode: | 227013979 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5408254557 | ||||||||
FaxNumber: | 5408254566 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/29/2005 | ||||||||
LastUpdateDate: | 05/17/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024170117 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 1497732549 | 05 | VA |   | MEDICAID | VV7473C | 01 | VA | MEDICARE | OTHER |