Provider Demographics
NPI:1821743493
Name:RUSSELL, KILA
Entity Type:Individual
Prefix:
First Name:KILA
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 1:3818 S LEE HWY
Mailing Address - Street 2:
Mailing Address - City:MC DONALD
Mailing Address - State:TN
Mailing Address - Zip Code:37353-5876
Mailing Address - Country:US
Mailing Address - Phone:423-320-7794
Mailing Address - Fax:
Practice Address - Street 1:3818 S LEE HWY
Practice Address - Street 2:
Practice Address - City:MC DONALD
Practice Address - State:TN
Practice Address - Zip Code:37353-5876
Practice Address - Country:US
Practice Address - Phone:423-320-7794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-13
Last Update Date:2022-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224P00000X
TN224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty