Provider Demographics
NPI:1053710053
Name:RUSSEFF, SHELLY RAE (APRN-CNP)
Entity type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:RAE
Last Name:RUSSEFF
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:R
Other - Last Name:ROBBINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN-CNP
Mailing Address - Street 1:301 E SEMINOLE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:OK
Mailing Address - Zip Code:73098-5629
Mailing Address - Country:US
Mailing Address - Phone:405-207-1116
Mailing Address - Fax:405-665-1001
Practice Address - Street 1:105 N INDIAN MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075-9236
Practice Address - Country:US
Practice Address - Phone:405-207-9800
Practice Address - Fax:405-207-9898
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-15
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0058066363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily