Basic Information
| Provider Information | |||||||||
| NPI: | 1932524261 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | KARAN | ||||||||
| MiddleName: | DAWN | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 SE 2ND ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640632759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192519830 | ||||||||
| FaxNumber: | 4192511826 | ||||||||
| Practice Location | |||||||||
| Address1: | 1532 LONE OAK RD STE 345 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704442250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2014 | ||||||||
| LastUpdateDate: | 01/30/2019 | ||||||||
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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 | 163W00000X | 77671 | KS | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 3011211 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7100484040 | 05 | KY | MEDICAID |