Basic Information
| Provider Information | |||||||||
| NPI: | 1982859237 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2817 SAINT JOHNS BLVD | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4176252300 | ||||||||
| FaxNumber: | 4176252005 | ||||||||
| Practice Location | |||||||||
| Address1: | 2817 SAINT JOHNS BLVD | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4176252300 | ||||||||
| FaxNumber: | 4176252005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2008 | ||||||||
| LastUpdateDate: | 02/10/2012 | ||||||||
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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 | 363LF0000X | 119130 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200249990A | 05 | OK | MEDICAID | 200587240C | 05 | KS | MEDICAID | 1982859237 | 05 | MO | MEDICAID |