MEDICARE: CONNIE RUSSELL

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	163W00000X	Registered Nurse	366691-3102	UT
2	363LF0000X	Family Nurse Practitioner	366691-4405	UT

General Provider Information

NPI Number	:	1518509637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNIE RUSSELL

Provider Business Mailing Address
First Line	:	9091 S EXCALIBER WAY
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84088-6583
Country	:	US
Telephone Number	:	801-824-7406
Fax Number	:

Provider Business Practice Location Address
First Line	:	1205 E BONNER WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4917
Country	:	US
Telephone Number	:	801-598-8337
Fax Number	:

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

Provider Enumeration Date	:	10/09/2019
Last Update Date	:	10/15/2020

Similar Medicare Providers

1689675340 — AVALON CARE CENTER-WILLOW WOOD, INC
Practice Location Address:

1205 E 4725 S
SALT LAKE CITY, UT
84117-4917

Practice Phone: 801-262-2908
Practice Fax: 801-262-2963

1215337811 — LEAH MANCINI OTR/L
Practice Location Address:

1205 E 4725 S
SALT LAKE CITY, UT
84117-4917

Practice Phone: 801-262-2908
Practice Fax:

1124591987 — GUNNISON VALLEY HOSPITAL
Practice Location Address:

1205 E 4725 S
SALT LAKE CITY, UT
84117-4917

Practice Phone: 801-262-2908
Practice Fax: 801-262-2963

1346134673 — SHELBY JANE STEFFENSEN
Practice Location Address:

1205 E BONNER WAY
MILLCREEK, UT
84117-4917

Practice Phone: 801-262-2908
Practice Fax:

1881563344 — KENADEE GROBERG
Practice Location Address:

1205 E BONNER WAY
MILLCREEK, UT
84117-4917

Practice Phone: 801-262-2908
Practice Fax:

1912772203 — KRISTIN KAY INGRAM
Practice Location Address:

1702 171ST AVE NE
HAM LAKE, MN
55304-4917

Practice Phone: 952-454-3655
Practice Fax:

Directions to “ CONNIE RUSSELL ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.