Healthcare Provider Details

I. General information

NPI: 1548170442
Provider Name (Legal Business Name): BREANNA RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MACCORKLE AVE SE
CHARLESTON WV
25304-1227
US

IV. Provider business mailing address

PO BOX 26
AMMA WV
25005-0026
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-8199
  • Fax:
Mailing address:
  • Phone: 304-651-8542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number127590
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: