Provider Demographics
NPI:1184933145
Name:STROUD, RUSSELL VAN (ACNP)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:VAN
Last Name:STROUD
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-5239
Mailing Address - Country:US
Mailing Address - Phone:479-575-4885
Mailing Address - Fax:479-575-3218
Practice Address - Street 1:118 W SPRING ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-5239
Practice Address - Country:US
Practice Address - Phone:479-575-4885
Practice Address - Fax:479-575-3218
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF430548-1363LA2100X
CANP19209363LA2100X
ARA03633363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care