Healthcare Provider Details

I. General information

NPI: 1386781060
Provider Name (Legal Business Name): KIMBERLEY A RUSSELL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 WALKER ST
KITTERY ME
03904-1727
US

IV. Provider business mailing address

100 SHATTUCK WAY STE 100
NEWINGTON NH
03801-8007
US

V. Phone/Fax

Practice location:
  • Phone: 207-439-4430
  • Fax: 207-439-0968
Mailing address:
  • Phone: 603-431-6677
  • Fax: 603-610-7713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP081884
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: