Healthcare Provider Details

I. General information

NPI: 1902149800
Provider Name (Legal Business Name): KATHRYN NIKOLE RUSSELL FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHRYN N SMITH FNP-BC

II. Dates (important events)

Enumeration Date: 03/29/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 NEW COVINGTON PIKE STE 112
MEMPHIS TN
38128-2526
US

IV. Provider business mailing address

3900 NEW COVINGTON PIKE STE 112
MEMPHIS TN
38128-2526
US

V. Phone/Fax

Practice location:
  • Phone: 901-376-6821
  • Fax: 901-609-7747
Mailing address:
  • Phone: 901-376-6821
  • Fax: 901-609-7747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA810604
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14717
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number17414
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: