MEDICARE: MS. TINA MARIE RUSSELL MSN, APRN, FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WG0000X	General Practice Registered Nurse	153147	TN
2	363LF0000X	Family Nurse Practitioner	APN0000028980	TN

General Provider Information

NPI Number	:	1295328342
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TINA MARIE RUSSELL MSN, APRN, FNP-C

Provider Business Mailing Address
First Line	:	15 OLD HUMBOLDT RD STE A
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-3506
Country	:	US
Telephone Number	:	731-256-6456
Fax Number	:	731-256-6475

Provider Business Practice Location Address
First Line	:	15 OLD HUMBOLDT RD
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-3506
Country	:	US
Telephone Number	:	731-256-6456
Fax Number	:	731-256-6475

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/18/2021
Last Update Date	:	04/18/2026

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