Healthcare Provider Details

I. General information

NPI: 1982017968
Provider Name (Legal Business Name): NICOLE ELIZABETH RUSSELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE ELIZABETH BIERIE

II. Dates (important events)

Enumeration Date: 06/06/2014
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 NORTH 6TH AVE.
SANDPOINT ID
83864
US

IV. Provider business mailing address

810 NORTH 6TH AVE.
SANDPOINT ID
83864
US

V. Phone/Fax

Practice location:
  • Phone: 208-265-6252
  • Fax:
Mailing address:
  • Phone: 208-265-6252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD494187
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMED-PHYS-LIC-58693
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-16119
License Number StateID
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME179868
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: