Healthcare Provider Details

I. General information

NPI: 1972891885
Provider Name (Legal Business Name): LAURA KATHRYN RUSSELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6060 PRIMACY PKWY STE 241
MEMPHIS TN
38119-5743
US

IV. Provider business mailing address

4036 N WALNUT GROVE CIR
MEMPHIS TN
38117-2210
US

V. Phone/Fax

Practice location:
  • Phone: 901-725-5846
  • Fax:
Mailing address:
  • Phone: 901-634-5003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number16735
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License Number23477
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number135778
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: