Healthcare Provider Details

I. General information

NPI: 1013727551
Provider Name (Legal Business Name): MELISSA CHERIE RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 N FREEDOM BLVD
PROVO UT
84601-1677
US

IV. Provider business mailing address

750 N FREEDOM BLVD
PROVO UT
84601-1677
US

V. Phone/Fax

Practice location:
  • Phone: 801-373-4760
  • Fax:
Mailing address:
  • Phone: 801-373-4760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number9515852-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: