Healthcare Provider Details

I. General information

NPI: 1710801964
Provider Name (Legal Business Name): SOUROU ALBAN AWADJIHE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2026
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 KELLY ST
MALVERN AR
72104-3471
US

IV. Provider business mailing address

1307 KELLY ST
MALVERN AR
72104-3471
US

V. Phone/Fax

Practice location:
  • Phone: 501-672-0299
  • Fax:
Mailing address:
  • Phone: 501-672-0299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1017335
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: