Healthcare Provider Details

I. General information

NPI: 1023798113
Provider Name (Legal Business Name): CAROLINE MICHELLE RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 S CHURCH ST STE A-B
LOCKHART TX
78644-2713
US

IV. Provider business mailing address

209 S CHURCH ST STE A-B
LOCKHART TX
78644-2713
US

V. Phone/Fax

Practice location:
  • Phone: 512-376-2999
  • Fax: 512-376-5562
Mailing address:
  • Phone: 512-376-2999
  • Fax: 512-376-5562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1129526
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: