MEDICARE: MARIE PHAM-RUSSELL DNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SF0001X	Family Health Clinical Nurse Specialist	A001764	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376538090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE PHAM-RUSSELL DNP

Provider Business Mailing Address
First Line	:	3108 BROOKEN HILL DR
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72908-9248
Country	:	US
Telephone Number	:	479-783-0233
Fax Number	:

Provider Business Practice Location Address
First Line	:	3202 N 6TH ST
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72904-4164
Country	:	US
Telephone Number	:	479-783-3900
Fax Number	:	479-783-3905

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2005
Last Update Date	:	03/20/2017

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