Healthcare Provider Details

I. General information

NPI: 1376538090
Provider Name (Legal Business Name): MARIE PHAM-RUSSELL DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3202 N 6TH ST
FORT SMITH AR
72904-4164
US

IV. Provider business mailing address

3108 BROOKEN HILL DR
FORT SMITH AR
72908-9248
US

V. Phone/Fax

Practice location:
  • Phone: 479-783-3900
  • Fax: 479-783-3905
Mailing address:
  • Phone: 479-783-0233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberA001764
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: