Provider Demographics
NPI:1053669721
Name:RUSSELL, REANNON (DPT)
Entity type:Individual
Prefix:
First Name:REANNON
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 JUMBO RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:AR
Mailing Address - Zip Code:72556-9175
Mailing Address - Country:US
Mailing Address - Phone:870-373-0532
Mailing Address - Fax:870-895-2626
Practice Address - Street 1:295 JUMBO RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:AR
Practice Address - Zip Code:72556-9175
Practice Address - Country:US
Practice Address - Phone:870-373-0532
Practice Address - Fax:870-895-2626
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3513225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist