Provider Demographics
NPI:1023089042
Name:RUSSELL, CAROL LYNN (CRNA)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 N 139TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66109-4234
Mailing Address - Country:US
Mailing Address - Phone:913-721-3641
Mailing Address - Fax:913-721-3649
Practice Address - Street 1:5520 COLLEGE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1630
Practice Address - Country:US
Practice Address - Phone:913-491-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS54607367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO910116805Medicaid
KS180055003Medicare PIN
MO910116805Medicaid
MOW49A00002Medicare PIN