Provider Demographics
NPI:1053635268
Name:RUSSELL, SHAVONNE M (PTA)
Entity Type:Individual
Prefix:
First Name:SHAVONNE
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 BILOXI RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-3310
Mailing Address - Country:US
Mailing Address - Phone:804-326-9245
Mailing Address - Fax:
Practice Address - Street 1:212 BILOXI RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-3310
Practice Address - Country:US
Practice Address - Phone:804-326-9245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306601563225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant