Provider Demographics
NPI:1639700925
Name:RUSSELL, CAITLYN
Entity type:Individual
Prefix:
First Name:CAITLYN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 FURYS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9059
Mailing Address - Country:US
Mailing Address - Phone:706-922-6179
Mailing Address - Fax:706-364-0416
Practice Address - Street 1:575 FURYS FERRY RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-9059
Practice Address - Country:US
Practice Address - Phone:706-691-7079
Practice Address - Fax:706-364-0416
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9732363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant