Provider Demographics
NPI:1922399849
Name:RUSSELL, ALEXANDRA DENISE (DPT)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:DENISE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:DENISE
Other - Last Name:COE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2725 N WESTWOOD BLVD
Mailing Address - Street 2:SUITE 17
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2346
Mailing Address - Country:US
Mailing Address - Phone:573-778-9348
Mailing Address - Fax:573-686-4870
Practice Address - Street 1:225 PHYSICIANS PARK
Practice Address - Street 2:SUITE 101
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3956
Practice Address - Country:US
Practice Address - Phone:573-778-9348
Practice Address - Fax:573-686-4870
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010031805225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist