MEDICARE: DR. NANCY KAE RUSSELL M.D.

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	207R00000X	Internal Medicine Physician	36094	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12799020	OTHER	MO	NON-PROVIDER # BCBS
2	68517	OTHER	KS	NON-PROVIDER # BCBS KS

General Provider Information

NPI Number	:	1790875425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NANCY KAE RUSSELL M.D.

Provider Business Mailing Address
First Line	:	5140 NE ANTIOCH RD
Second Line	:	NURTURING OPTIMAL WELLNESS
City	:	KANSAS CITY
State	:	MO
Zip	:	64119-2523
Country	:	US
Telephone Number	:	816-453-5545
Fax Number	:	800-261-2718

Provider Business Practice Location Address
First Line	:	5140 NE ANTIOCH RD
Second Line	:	NURTURING OPTIMAL WELLNESS
City	:	KANSAS CITY
State	:	MO
Zip	:	64119-2523
Country	:	US
Telephone Number	:	816-453-5545
Fax Number	:	800-261-2718

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

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	12/07/2018

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