Provider Demographics
NPI:1851650469
Name:RUSSELL, ALECIA NICOLE (DO)
Entity Type:Individual
Prefix:
First Name:ALECIA
Middle Name:NICOLE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1090
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95241-1090
Mailing Address - Country:US
Mailing Address - Phone:209-334-1800
Mailing Address - Fax:209-334-2416
Practice Address - Street 1:999 S FAIRMONT AVE
Practice Address - Street 2:STE. 230
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5100
Practice Address - Country:US
Practice Address - Phone:209-334-4924
Practice Address - Fax:209-334-0127
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A14816207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology