MEDICARE: EMMA KATHERINE RUSSELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1457135857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMA KATHERINE RUSSELL

Provider Business Mailing Address
First Line	:	217 COFFEE RD
Second Line	:
City	:	LYNCHBURG
State	:	VA
Zip	:	24503-3809
Country	:	US
Telephone Number	:	434-213-4656
Fax Number	:

Provider Business Practice Location Address
First Line	:	217 COFFEE RD
Second Line	:
City	:	LYNCHBURG
State	:	VA
Zip	:	24503-3809
Country	:	US
Telephone Number	:	434-213-4656
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2023
Last Update Date	:	08/24/2023

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