=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053192104
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLLEEN K. RUSSELL C.N.P.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2023
-----------------------------------------------------
Last Update Date | 01/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29099 HEALTH CAMPUS DRIVE SUITE 280
-----------------------------------------------------
City | WESTLAKE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44145-4414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-293-0282
-----------------------------------------------------
Fax | 440-455-9757
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29099 HEALTH CAMPUS DRIVE SUITE 280
-----------------------------------------------------
City | WESTLAKE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44145-5200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-293-0282
-----------------------------------------------------
Fax | 440-455-9757
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.0033973
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------