Provider Demographics
NPI:1598353724
Name:RUSSELL, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
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 1:6 MATHIS DR NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1242
Mailing Address - Country:US
Mailing Address - Phone:706-233-9023
Mailing Address - Fax:706-295-1585
Practice Address - Street 1:6 MATHIS DR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1242
Practice Address - Country:US
Practice Address - Phone:706-233-9023
Practice Address - Fax:706-295-1585
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN234419163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health