Provider Demographics
NPI:1790180248
Name:RUSSELL, DEVIN DEE (FNP-C)
Entity Type:Individual
Prefix:
First Name:DEVIN
Middle Name:DEE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 740
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832-0740
Mailing Address - Country:US
Mailing Address - Phone:870-584-3000
Mailing Address - Fax:870-584-3003
Practice Address - Street 1:167 SCHOOL DRIVE
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832-7183
Practice Address - Country:US
Practice Address - Phone:870-584-3000
Practice Address - Fax:870-584-3003
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126756363LF0000X
ARA004533363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR212772758Medicaid