Healthcare Provider Details

I. General information

NPI: 1730747817
Provider Name (Legal Business Name): TIERAH RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIERAH JOHNSON

II. Dates (important events)

Enumeration Date: 06/03/2019
Last Update Date: 06/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2911 LEISURE WOODS LN
DECATUR GA
30034-3430
US

IV. Provider business mailing address

2911 LEISURE WOODS LN
DECATUR GA
30034-3430
US

V. Phone/Fax

Practice location:
  • Phone: 404-834-1735
  • Fax:
Mailing address:
  • Phone: 404-834-1735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: