Provider Demographics
NPI:1588798235
Name:RUSSELL, ANGELA (MSPT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-2940
Mailing Address - Country:US
Mailing Address - Phone:501-249-7413
Mailing Address - Fax:
Practice Address - Street 1:8109 INTERSTATE 30
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-4840
Practice Address - Country:US
Practice Address - Phone:501-249-7413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT#2213174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist