Healthcare Provider Details

I. General information

NPI: 1417617507
Provider Name (Legal Business Name): HANNAH RUSSELL AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2021
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 L ST
SACRAMENTO CA
95816-5616
US

IV. Provider business mailing address

8136 RYLAND DR
EL DORADO HILLS CA
95762-9452
US

V. Phone/Fax

Practice location:
  • Phone: 440-539-6491
  • Fax:
Mailing address:
  • Phone: 440-539-6491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95018691
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95239867
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: