Healthcare Provider Details

I. General information

NPI: 1639611767
Provider Name (Legal Business Name): RUSSELL SMITH RN., FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2016
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 BAY DALE DR
ARNOLD MD
21012-2325
US

IV. Provider business mailing address

2440 LIZBEC CT
CROFTON MD
21114-3246
US

V. Phone/Fax

Practice location:
  • Phone: 410-757-0027
  • Fax:
Mailing address:
  • Phone: 301-801-6725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR182595
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: