Basic Information
| Provider Information | |||||||||
| NPI: | 1578523452 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 EAST LIBERTY | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025403339 | ||||||||
| FaxNumber: | 5024791425 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 ABRAHAM FLEXNER WAY | ||||||||
| Address2: | SUITE 904 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025893844 | ||||||||
| FaxNumber: | 5025890516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 03/20/2018 | ||||||||
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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 | 363L00000X | 4726P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 3004726 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7100478420 | 05 | KY | MEDICAID |