Provider Demographics
NPI:1376538090
Name:PHAM-RUSSELL, MARIE (DNP)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:PHAM-RUSSELL
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3108 BROOKEN HILL DR
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-9248
Mailing Address - Country:US
Mailing Address - Phone:479-783-0233
Mailing Address - Fax:
Practice Address - Street 1:3202 N 6TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72904-4164
Practice Address - Country:US
Practice Address - Phone:479-783-3900
Practice Address - Fax:479-783-3905
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA001764364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR165901758Medicaid
AR165901758Medicaid