Healthcare Provider Details

I. General information

NPI: 1003578642
Provider Name (Legal Business Name): ANNA MARIE RUSSELL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNA MARIE RUSSELL

II. Dates (important events)

Enumeration Date: 10/12/2021
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 EASTER AVE
WEAVERVILLE CA
96093-8054
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 530-623-4186
  • Fax: 530-623-4397
Mailing address:
  • Phone: 208-302-9342
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8471097
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95026495
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: