Provider Demographics
NPI:1366811721
Name:CORYELL, RUSSELL DAVID (CNP-FNP)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:DAVID
Last Name:CORYELL
Suffix:
Gender:M
Credentials:CNP-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 S VALLEY DR STE B
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3165
Mailing Address - Country:US
Mailing Address - Phone:575-526-6992
Mailing Address - Fax:575-526-7983
Practice Address - Street 1:1455 S VALLEY DR STE B
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3165
Practice Address - Country:US
Practice Address - Phone:575-526-6992
Practice Address - Fax:575-526-7983
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02762363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily