Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 175L00000X | Homeopath |
NPI | 1730747817 |
---|---|
Provider Name | Tierah Russell |
First Address | Decatur, GA 30034-3430 |
Second Address | Decatur, GA 30034-3430 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/06/2019 |
Last Update Date | 03/06/2019 |