Provider Demographics
NPI:1891798377
Name:RUSSELL, LORI (PA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:
Other - Last Name:NEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 HUNTERS LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-8263
Mailing Address - Country:US
Mailing Address - Phone:931-455-4616
Mailing Address - Fax:931-455-2362
Practice Address - Street 1:100 HUNTERS LN
Practice Address - Street 2:SUITE 100
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-8263
Practice Address - Country:US
Practice Address - Phone:931-455-4616
Practice Address - Fax:931-455-2362
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1198363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical