Healthcare Provider Details

I. General information

NPI: 1144053422
Provider Name (Legal Business Name): ANIYAH NICOLE RUSSELL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD
DECATUR GA
30033-4004
US

IV. Provider business mailing address

3418 TABLE ROCK DR
GASTONIA NC
28052-5436
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax:
Mailing address:
  • Phone: 704-606-0501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number357577
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: