Provider Demographics
NPI:1588470538
Name:RUSSAW, OLIVIA HICKS
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:HICKS
Last Name:RUSSAW
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 1:58 NOMAD CIR
Mailing Address - Street 2:
Mailing Address - City:KINSEY
Mailing Address - State:AL
Mailing Address - Zip Code:36303-7752
Mailing Address - Country:US
Mailing Address - Phone:334-405-6206
Mailing Address - Fax:
Practice Address - Street 1:58 NOMAD CIR
Practice Address - Street 2:
Practice Address - City:KINSEY
Practice Address - State:AL
Practice Address - Zip Code:36303-7752
Practice Address - Country:US
Practice Address - Phone:334-405-6206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL48582278E1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278E1000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedEducational