=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790180248
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEVIN DEE RUSSELL FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2014
-----------------------------------------------------
Last Update Date | 02/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 167 SCHOOL DRIVE
-----------------------------------------------------
City | DE QUEEN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71832-7183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-584-3000
-----------------------------------------------------
Fax | 870-584-3003
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 740
-----------------------------------------------------
City | DE QUEEN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71832-0740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-584-3000
-----------------------------------------------------
Fax | 870-584-3003
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP126756
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | A004533
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------