Provider Demographics
NPI:1255189130
Name:RUSSELL, TIONNA SHARELL
Entity type:Individual
Prefix:
First Name:TIONNA
Middle Name:SHARELL
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 1:9450 E 48TH PL APT 137F
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-7357
Mailing Address - Country:US
Mailing Address - Phone:539-292-6612
Mailing Address - Fax:
Practice Address - Street 1:9450 E 48TH PL APT 137F
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-7357
Practice Address - Country:US
Practice Address - Phone:539-292-6612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK082261035175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist