Provider Demographics
NPI:1790193563
Name:RUSSELL, AGNES MACFIE
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:MACFIE
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 1:211 W LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29180-1421
Mailing Address - Country:US
Mailing Address - Phone:803-635-6481
Mailing Address - Fax:
Practice Address - Street 1:1136 KINCAID BRIDGE RD
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:SC
Practice Address - Zip Code:29180-7116
Practice Address - Country:US
Practice Address - Phone:803-635-6481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC272133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic