Provider Demographics
NPI:1750491817
Name:RUSSELL, ABIGAIL
Entity Type:Individual
Prefix:
First Name:ABIGAIL
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 1:1016 GRANITE LN
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-2377
Mailing Address - Country:US
Mailing Address - Phone:770-554-6750
Mailing Address - Fax:
Practice Address - Street 1:142 GA STATE HIGHWAY 138
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655
Practice Address - Country:US
Practice Address - Phone:770-207-1137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPTA001474OtherLICENSE#