Healthcare Provider Details

I. General information

NPI: 1295182012
Provider Name (Legal Business Name): MS. JOANNA NOEL RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4021 W WALNUT ST # 1132
ROGERS AR
72756-1842
US

IV. Provider business mailing address

4021 W WALNUT ST # 1132
ROGERS AR
72756-1842
US

V. Phone/Fax

Practice location:
  • Phone: 479-310-5483
  • Fax:
Mailing address:
  • Phone: 479-310-5483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9025-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: