Provider Demographics
NPI:1053695742
Name:RUSSELL, ALLISON MARIE (ATC)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10749 E 29TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74129-7805
Mailing Address - Country:US
Mailing Address - Phone:918-810-6293
Mailing Address - Fax:
Practice Address - Street 1:500 E BORDER ST STE 250
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76010-7445
Practice Address - Country:US
Practice Address - Phone:918-810-6293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0417171W00000X
OK4172255A2300X
TX65962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No171W00000XOther Service ProvidersContractor