Provider Demographics
NPI:1063214658
Name:RUSSELL, EMMA GRACE
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:GRACE
Last Name:RUSSELL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 PATRICK HENRY ST
Mailing Address - Street 2:
Mailing Address - City:RED BAY
Mailing Address - State:AL
Mailing Address - Zip Code:35582-3640
Mailing Address - Country:US
Mailing Address - Phone:256-460-8306
Mailing Address - Fax:
Practice Address - Street 1:703 PATRICK HENRY ST
Practice Address - Street 2:
Practice Address - City:RED BAY
Practice Address - State:AL
Practice Address - Zip Code:35582-3640
Practice Address - Country:US
Practice Address - Phone:256-460-8306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS13894390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program