Provider Demographics
NPI:1215184643
Name:RUSSELL, AMY RENEE (ARNP)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:RENEE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:RENEE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:369 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-3541
Mailing Address - Country:US
Mailing Address - Phone:850-398-6963
Mailing Address - Fax:850-398-8277
Practice Address - Street 1:369 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-3541
Practice Address - Country:US
Practice Address - Phone:850-332-2589
Practice Address - Fax:850-398-8277
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9226261163W00000X
FLARNP9226261363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNONEMedicaid