Provider Demographics
NPI:1902149800
Name:RUSSELL, KATHRYN NIKOLE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:NIKOLE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MS
Other - First Name:KATHRYN
Other - Middle Name:N
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:3900 NEW COVINGTON PIKE STE 112
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-2526
Mailing Address - Country:US
Mailing Address - Phone:901-376-6821
Mailing Address - Fax:901-609-7747
Practice Address - Street 1:3900 NEW COVINGTON PIKE STE 112
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-2526
Practice Address - Country:US
Practice Address - Phone:901-376-6821
Practice Address - Fax:901-609-7747
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA810604363LF0000X
TN14717363LF0000X
TN17414363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily