Healthcare Provider Details

I. General information

NPI: 1891798377
Provider Name (Legal Business Name): LORI RUSSELL P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LORI NEAL P.A.

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 07/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HUNTERS LN SUITE 100
TULLAHOMA TN
37388-8263
US

IV. Provider business mailing address

100 HUNTERS LN SUITE 100
TULLAHOMA TN
37388-8263
US

V. Phone/Fax

Practice location:
  • Phone: 931-455-4616
  • Fax: 931-455-2362
Mailing address:
  • Phone: 931-455-4616
  • Fax: 931-455-2362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1198
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: