Provider Demographics
NPI:1730514316
Name:RUSSELL, LISA DAWN (NP-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DAWN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18033 COUNTY ROAD 500 E
Mailing Address - Street 2:
Mailing Address - City:DAHLGREN
Mailing Address - State:IL
Mailing Address - Zip Code:62828-4294
Mailing Address - Country:US
Mailing Address - Phone:618-648-2668
Mailing Address - Fax:
Practice Address - Street 1:1343 COUNTY ROAD 1450 E
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821-5205
Practice Address - Country:US
Practice Address - Phone:618-382-2103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-13
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28101863A363LF0000X
IL209.012482363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily