Healthcare Provider Details

I. General information

NPI: 1396961827
Provider Name (Legal Business Name): RUSSELL ROUSE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 WHITTINGTON AVE
HOT SPRINGS AR
71901-3407
US

IV. Provider business mailing address

311 WHITTINGTON AVE
HOT SPRINGS AR
71901-3407
US

V. Phone/Fax

Practice location:
  • Phone: 501-623-3477
  • Fax: 501-624-7498
Mailing address:
  • Phone: 501-623-3477
  • Fax: 501-624-7498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR77089
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: