Provider Demographics
NPI:1679830228
Name:RUSSELL, ANGEL NICOLE (EDS)
Entity Type:Individual
Prefix:MRS
First Name:ANGEL
Middle Name:NICOLE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 NE 67TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-1238
Mailing Address - Country:US
Mailing Address - Phone:405-514-0484
Mailing Address - Fax:
Practice Address - Street 1:35 NE 67TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-1238
Practice Address - Country:US
Practice Address - Phone:405-514-0484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-20
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200330980Medicaid