Provider Demographics
NPI:1316768823
Name:RUSSAVAGE, TAMIKA JEAN
Entity type:Individual
Prefix:
First Name:TAMIKA
Middle Name:JEAN
Last Name:RUSSAVAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14568 CORBY ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-5104
Mailing Address - Country:US
Mailing Address - Phone:402-334-8369
Mailing Address - Fax:531-299-1099
Practice Address - Street 1:1807 S 60TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68106-2151
Practice Address - Country:US
Practice Address - Phone:531-299-1080
Practice Address - Fax:531-299-1099
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE69653163W00000X, 163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
No163W00000XNursing Service ProvidersRegistered Nurse