Healthcare Provider Details

I. General information

NPI: 1194283721
Provider Name (Legal Business Name): GREGORY RUSSELL APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2019
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

1138 CAMIN LN
WALTON KY
41094-7506
US

V. Phone/Fax

Practice location:
  • Phone: 859-743-1083
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WF0300X
TaxonomyFlight Registered Nurse
License NumberRN.365577
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN.CNP.025098
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number025098
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: