Healthcare Provider Details

I. General information

NPI: 1205838661
Provider Name (Legal Business Name): TERRI LYNNE RUSSELL RN MS CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: TERRI LYNNE FOWLES RN

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 E 1ST ST
WACONIA MN
55387-1601
US

IV. Provider business mailing address

540 E 1ST ST
WACONIA MN
55387-1601
US

V. Phone/Fax

Practice location:
  • Phone: 952-442-4437
  • Fax: 952-442-3084
Mailing address:
  • Phone: 952-442-4437
  • Fax: 952-442-3084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR-122719-6
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: