Provider Demographics
NPI:1417069725
Name:MULLINS-RUSSELL, ANGELA RENEE
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:RENEE
Last Name:MULLINS-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 1:711 W MORGAN AVE
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24277
Mailing Address - Country:US
Mailing Address - Phone:276-546-5289
Mailing Address - Fax:276-546-5289
Practice Address - Street 1:711 W MORGAN AVE
Practice Address - Street 2:
Practice Address - City:PENNINGTON GAP
Practice Address - State:VA
Practice Address - Zip Code:24277
Practice Address - Country:US
Practice Address - Phone:276-546-5289
Practice Address - Fax:276-546-5289
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002292101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA143331OtherANTHEM BLUE CROSS