Healthcare Provider Details

I. General information

NPI: 1134671126
Provider Name (Legal Business Name): SANDRA ALLISON RUSSELL NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 STATE HIGHWAY 30 W
NEW ALBANY MS
38652-3112
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 315
MEMPHIS TN
38120-9401
US

V. Phone/Fax

Practice location:
  • Phone: 662-538-2438
  • Fax: 662-538-2442
Mailing address:
  • Phone: 877-348-1281
  • Fax: 901-227-3206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberAG0916010
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: