Healthcare Provider Details

I. General information

NPI: 1679344089
Provider Name (Legal Business Name): CHASSIDY MERCEDES RUSSELL MSN, APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 AVENUE C
WEST POINT GA
31833-1642
US

IV. Provider business mailing address

4749 IRISH RED CT
UNION CITY GA
30291-3480
US

V. Phone/Fax

Practice location:
  • Phone: 762-209-8009
  • Fax:
Mailing address:
  • Phone: 229-942-5927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2023127904
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: