Provider Demographics
NPI:1588215966
Name:RUSSELL, VENIUS VERNESTER
Entity Type:Individual
Prefix:
First Name:VENIUS
Middle Name:VERNESTER
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 GRACE LOOP
Mailing Address - Street 2:
Mailing Address - City:DERMOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71638-8763
Mailing Address - Country:US
Mailing Address - Phone:870-538-8284
Mailing Address - Fax:
Practice Address - Street 1:2200 FORT ROOTS DR
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-1709
Practice Address - Country:US
Practice Address - Phone:501-257-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant