Provider Demographics
NPI:1629408463
Name:RUSSELL-MCADORY, DENIECE
Entity type:Individual
Prefix:
First Name:DENIECE
Middle Name:
Last Name:RUSSELL-MCADORY
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 1:6705 W HIGHWAY 290 STE 607
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8408
Mailing Address - Country:US
Mailing Address - Phone:512-843-5169
Mailing Address - Fax:512-856-6238
Practice Address - Street 1:6705 W HIGHWAY 290 STE 607
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-8408
Practice Address - Country:US
Practice Address - Phone:512-843-5169
Practice Address - Fax:512-856-6238
Is Sole Proprietor?:No
Enumeration Date:2013-11-14
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR874534363L00000X
TX1058694363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02672568Medicaid