Basic Information
| Provider Information | |||||||||
| NPI: | 1275637639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | TANGELLA | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SNEED | ||||||||
| OtherFirstName: | TANGELLA | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 20 FRANCIS WAY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SHARPSBURG | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702530611 | ||||||||
| FaxNumber: | 7705020521 | ||||||||
| Practice Location | |||||||||
| Address1: | 1267 HIGHWAY 54 W | ||||||||
| Address2: | SUITE 2200 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302142114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707160051 | ||||||||
| FaxNumber: | 7707160087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 09/15/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN 116405 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 087974374G | 05 | GA | MEDICAID |