Provider Demographics
NPI:1356843379
Name:RUSSELL, FATIA A
Entity Type:Individual
Prefix:
First Name:FATIA
Middle Name:A
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6245 LAKEHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-0610
Mailing Address - Country:US
Mailing Address - Phone:910-479-6214
Mailing Address - Fax:
Practice Address - Street 1:6245 LAKEHAVEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-0610
Practice Address - Country:US
Practice Address - Phone:910-479-6214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2019-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC108796224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC108796Medicaid