MEDICARE: STELLA MARDETA RUSSELL FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	APRN.CNP.0027561	OH

General Provider Information

NPI Number	:	1083220628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STELLA MARDETA RUSSELL FNP

Provider Business Mailing Address
First Line	:	20050 HARVARD AVE STE 300
Second Line	:
City	:	WARRENSVILLE HEIGHTS
State	:	OH
Zip	:	44122-6800
Country	:	US
Telephone Number	:	216-751-1212
Fax Number	:

Provider Business Practice Location Address
First Line	:	20050 HARVARD AVE STE 300
Second Line	:
City	:	WARRENSVILLE HEIGHTS
State	:	OH
Zip	:	44122-6800
Country	:	US
Telephone Number	:	216-751-1212
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2020
Last Update Date	:	01/10/2022

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