Healthcare Provider Details

I. General information

NPI: 1477066264
Provider Name (Legal Business Name): CLAIRE RUSSELL FAMILY MEDICAL CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2017
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W COLLIN RAYE DR STE 101B
DE QUEEN AR
71832-2003
US

IV. Provider business mailing address

300 W COLLIN RAYE DR STE 101B
DE QUEEN AR
71832-2003
US

V. Phone/Fax

Practice location:
  • Phone: 903-280-2813
  • Fax:
Mailing address:
  • Phone: 903-280-2813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KATINA R LEVINGSTON
Title or Position: MANAGER
Credential:
Phone: 903-293-7093