Provider Demographics
NPI:1497252282
Name:RUSSELL, ABIGAIL L (DO)
Entity Type:Individual
Prefix:DR
First Name:ABIGAIL
Middle Name:L
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4976 ALPHA LN
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-5470
Mailing Address - Country:US
Mailing Address - Phone:423-497-5355
Mailing Address - Fax:
Practice Address - Street 1:1008 EXECUTIVE DR STE 104
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-3992
Practice Address - Country:US
Practice Address - Phone:423-954-9017
Practice Address - Fax:423-498-1597
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4703207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program