Basic Information
| Provider Information | |||||||||
| NPI: | 1598353724 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | KIM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 MATHIS DR NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062339023 | ||||||||
| FaxNumber: | 7062951585 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 MATHIS DR NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062339023 | ||||||||
| FaxNumber: | 7062951585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2021 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | RN234419 | GA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.