Basic Information
| Provider Information | |||||||||
| NPI: | 1851744130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | KATHLEEN | ||||||||
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| Credential: | AGPCNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6069 | ||||||||
| Address2: | |||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291716069 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 146 EAST HOSPITAL DR | ||||||||
| Address2: | 140 | ||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291694800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039367230 | ||||||||
| FaxNumber: | 8039368097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2016 | ||||||||
| LastUpdateDate: | 11/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 20237 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | 20237 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP2300X | 20237 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363L00000X | 20237 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.