Healthcare Provider Details

I. General information

NPI: 1780524850
Provider Name (Legal Business Name): EMILY D RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2808 S PICHER AVE
JOPLIN MO
64804-1645
US

IV. Provider business mailing address

PO BOX 2526
JOPLIN MO
64803-2526
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-7825
  • Fax: 417-347-9727
Mailing address:
  • Phone: 417-347-7825
  • Fax: 417-347-9727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: