Provider Demographics
NPI:1144239658
Name:RUSSELL, ALLISON (PA)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4024 N MOUNT JULIET RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-3086
Mailing Address - Country:US
Mailing Address - Phone:615-773-9393
Mailing Address - Fax:615-773-9238
Practice Address - Street 1:4024 N MOUNT JULIET RD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-3086
Practice Address - Country:US
Practice Address - Phone:615-773-9393
Practice Address - Fax:615-773-9238
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN720363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN720OtherSTATE LICENSE