| Doctor Name: | SANDRA G RUSSELL |
| NPI Number: | 1932219581 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | CNP |
| License Number: | R639834 |
| Business Practice Address: | 15 Pumping Station Rd Petal, MS - 394658325 |
| Business Phone Number: | 6015831559 |
| Business Fax Number: | 6015831573 |
| Mailing Address: | 415 S 28th Ave, HATTIESBURG |
| State: | MS |
| Postal Code: | 394017246 |
| Phone Number: | 6015795463 |
| Fax Number: | 6015795240 |
| NPI Enumeration Date: | 08/30/2006 |
| NPI Last Update Date: | 02/05/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | R639834 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MS |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |