Healthcare Provider Details

I. General information

NPI: 1700566478
Provider Name (Legal Business Name): STEPHANIE MAY RUSSELL DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2023
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N BROADWAY ST
BALTIMORE MD
21287-0031
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-8964
  • Fax:
Mailing address:
  • Phone: 410-933-2704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR212338
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR212338
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: