Provider Demographics
NPI:1275637639
Name:RUSSELL, TANGELLA E (CNP)
Entity Type:Individual
Prefix:
First Name:TANGELLA
Middle Name:E
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:TANGELLA
Other - Middle Name:E
Other - Last Name:SNEED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 FRANCIS WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SHARPSBURG
Mailing Address - State:GA
Mailing Address - Zip Code:30277
Mailing Address - Country:US
Mailing Address - Phone:770-253-0611
Mailing Address - Fax:770-502-0521
Practice Address - Street 1:1267 HIGHWAY 54 W
Practice Address - Street 2:SUITE 2200
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2114
Practice Address - Country:US
Practice Address - Phone:770-716-0051
Practice Address - Fax:770-716-0087
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN 116405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA087974374GMedicaid
Q25697Medicare UPIN
GA202I502193Medicare PIN