MEDICARE: BRENDA SIMASIKU RUSS

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	8307	MN

General Provider Information

NPI Number	:	1902579626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA SIMASIKU RUSS

Provider Business Mailing Address
First Line	:	10200 HIDDEN OAKS LN N
Second Line	:
City	:	CHAMPLIN
State	:	MN
Zip	:	55316-3043
Country	:	US
Telephone Number	:	612-432-6964
Fax Number	:

Provider Business Practice Location Address
First Line	:	2105 W 143RD ST # 2ND
Second Line	:
City	:	BURNSVILLE
State	:	MN
Zip	:	55306-8000
Country	:	US
Telephone Number	:	952-303-6832
Fax Number	:

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

Provider Enumeration Date	:	07/28/2021
Last Update Date	:	09/24/2021

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Directions to “ BRENDA SIMASIKU RUSS ” Practice Location

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