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General NPI Number Information
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NPI Number | 1295328342
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Entity Type | Individual
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Provider Name | TINA MARIE RUSSELL MSN, APRN, FNP-C
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Gender | Female
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Dates
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Enumeration Date | 02/18/2021
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Last Update Date | 04/18/2026
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Provider Practice Location Address
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Address Line | 15 OLD HUMBOLDT RD
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City | JACKSON
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State | TN
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Zip | 38305-3506
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Country | US
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Telephone | 731-256-6456
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Fax | 731-256-6475
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Provider Business Mailing Address
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Address Line | 15 OLD HUMBOLDT RD STE A
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City | JACKSON
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State | TN
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Zip | 38305-3506
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Country | US
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Telephone | 731-256-6456
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Fax | 731-256-6475
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WG0000X
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Taxonomy Name | General Practice Registered Nurse
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License Number | 153147
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | APN0000028980
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License Number State | TN
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