Provider Demographics
NPI:1598219537
Name:RUSSELL, HEATHER LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LYNN
Other - Last Name:OSBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 161463
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30321-1463
Mailing Address - Country:US
Mailing Address - Phone:776-369-5440
Mailing Address - Fax:706-369-5490
Practice Address - Street 1:120 HAWTHORNE PARK
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606
Practice Address - Country:US
Practice Address - Phone:776-353-8700
Practice Address - Fax:706-353-6629
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008051363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant