Healthcare Provider Details

I. General information

NPI: 1770702979
Provider Name (Legal Business Name): DEIDRE MICHELLE RUSSELL CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 NW 43RD ST
GAINESVILLE FL
32607-6110
US

IV. Provider business mailing address

724 NW 43RD ST
GAINESVILLE FL
32607-6110
US

V. Phone/Fax

Practice location:
  • Phone: 352-332-7222
  • Fax: 352-332-7330
Mailing address:
  • Phone: 352-332-7222
  • Fax: 352-332-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number1757432
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: