=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992880926
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONICA L RUSSELL LPTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 JORDAN LN
-----------------------------------------------------
City | PARSONS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38363-5078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-847-7240
-----------------------------------------------------
Fax | 731-660-5972
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 MAYFIELD RD
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38340-4063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-989-9814
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2366
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------