Provider Demographics
NPI:1053192104
Name:RUSSELL, COLLEEN K (CNP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:K
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29099 HEALTH CAMPUS DRIVE
Mailing Address - Street 2:SUITE 280
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-5200
Mailing Address - Country:US
Mailing Address - Phone:216-293-0282
Mailing Address - Fax:440-455-9757
Practice Address - Street 1:29099 HEALTH CAMPUS DRIVE
Practice Address - Street 2:SUITE 280
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-4414
Practice Address - Country:US
Practice Address - Phone:216-293-0282
Practice Address - Fax:440-455-9757
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0033973363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAPRN.CNP.0033973OtherOHIO ELICENSURE OHIO PROFESSIONAL LICENSURE/ANCC
OHRN.436667OtherOHIO ELICENSURE OHIO PROFESSIONAL LICENSURE