MEDICARE: CAROLINA WREN RUSSELL NP

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	36643	TN

General Provider Information

NPI Number	:	1326868837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLINA WREN RUSSELL NP

Provider Business Mailing Address
First Line	:	890 ISABELLA LN
Second Line	:
City	:	SMYRNA
State	:	TN
Zip	:	37167-4215
Country	:	US
Telephone Number	:	615-768-8021
Fax Number	:

Provider Business Practice Location Address
First Line	:	890 ISABELLA LN
Second Line	:
City	:	SMYRNA
State	:	TN
Zip	:	37167-4215
Country	:	US
Telephone Number	:	615-768-8021
Fax Number	:

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

Provider Enumeration Date	:	10/10/2024
Last Update Date	:	10/10/2024

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