=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871640250
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BILLIE J RUSSELL ARNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2007
-----------------------------------------------------
Last Update Date | 10/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4348 SOUTHPOINT BLVD STE 100
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-0903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-434-6169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 756 COUNTY ROAD 13 SOUTH
-----------------------------------------------------
City | ST. AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-501-1903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 315762
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------