Provider Demographics
NPI:1184186397
Name:RUSSELL, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 NEW HAMPSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE STATION
Mailing Address - State:IN
Mailing Address - Zip Code:46405-1346
Mailing Address - Country:US
Mailing Address - Phone:219-671-6187
Mailing Address - Fax:
Practice Address - Street 1:1100 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-1711
Practice Address - Country:US
Practice Address - Phone:219-885-4264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27056440A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse