Provider Demographics
NPI:1366562712
Name:VARISCO-RUSSELL, KAREN MICHELE (PTA)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:MICHELE
Last Name:VARISCO-RUSSELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:MICHELE
Other - Last Name:VARISCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:136 MAPLE HILL DR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-5580
Mailing Address - Country:US
Mailing Address - Phone:770-253-5443
Mailing Address - Fax:
Practice Address - Street 1:1255 HIGHWAY 54 W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4526
Practice Address - Country:US
Practice Address - Phone:770-719-7183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA001748225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant