Provider Demographics
NPI:1841500923
Name:RUSSELL, LANITA KAYE (PT,DPT)
Entity type:Individual
Prefix:MRS
First Name:LANITA
Middle Name:KAYE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S MAIN ST STE 500
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-6848
Mailing Address - Country:US
Mailing Address - Phone:501-278-9904
Mailing Address - Fax:501-278-9906
Practice Address - Street 1:400 S MAIN ST STE 500
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-6848
Practice Address - Country:US
Practice Address - Phone:501-278-9904
Practice Address - Fax:501-278-9906
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT,DPT 3303225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR183978721Medicaid