Healthcare Provider Details

I. General information

NPI: 1144103649
Provider Name (Legal Business Name): ERIN RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2025
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SAINT JOHNS BLVD STE 200
MAPLEWOOD MN
55109-1190
US

IV. Provider business mailing address

4491 W 131ST ST
SAVAGE MN
55378-1691
US

V. Phone/Fax

Practice location:
  • Phone: 651-326-4327
  • Fax:
Mailing address:
  • Phone: 952-715-0486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number12920
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: