MEDICARE: STEPHANIE N RUSSELL FNP-BC

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	COA11080	OH

General Provider Information

NPI Number	:	1891019758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE N RUSSELL FNP-BC

Provider Business Mailing Address
First Line	:	350 MEADOWS DR
Second Line	:
City	:	SPRINGBORO
State	:	OH
Zip	:	45066-8649
Country	:	US
Telephone Number	:	937-286-4024
Fax Number	:

Provider Business Practice Location Address
First Line	:	3572 DAYTON XENIA RD
Second Line	:
City	:	BEAVERCREEK
State	:	OH
Zip	:	45432-2886
Country	:	US
Telephone Number	:	937-427-4600
Fax Number	:

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

Provider Enumeration Date	:	03/22/2010
Last Update Date	:	08/03/2016

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