Healthcare Provider Details

I. General information

NPI: 1588470538
Provider Name (Legal Business Name): OLIVIA HICKS RUSSAW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 NOMAD CIR
KINSEY AL
36303-7752
US

IV. Provider business mailing address

58 NOMAD CIR
KINSEY AL
36303-7752
US

V. Phone/Fax

Practice location:
  • Phone: 334-405-6206
  • Fax:
Mailing address:
  • Phone: 334-405-6206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2278E1000X
TaxonomyEducational Certified Respiratory Therapist
License Number4858
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: