MEDICARE: DR. ELIZABETH ALEXIS RUSSELL DNP, APRN, FNP-BC

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	363LF0000X	Family Nurse Practitioner	71016727A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518779966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH ALEXIS RUSSELL DNP, APRN, FNP-BC

Provider Business Mailing Address
First Line	:	1122 S IRONWOOD DR
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46615-1618
Country	:	US
Telephone Number	:	574-335-8399
Fax Number	:	574-335-0786

Provider Business Practice Location Address
First Line	:	1122 S IRONWOOD DR
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46615-1618
Country	:	US
Telephone Number	:	574-335-8399
Fax Number	:	574-335-0786

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

Provider Enumeration Date	:	01/23/2025
Last Update Date	:	11/20/2025

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