Provider Demographics
NPI:1023884640
Name:RUSSELL, AMONAE DANYEL (APRN)
Entity type:Individual
Prefix:
First Name:AMONAE
Middle Name:DANYEL
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 MISTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-2295
Mailing Address - Country:US
Mailing Address - Phone:803-830-0541
Mailing Address - Fax:
Practice Address - Street 1:425 MISTWOOD CT
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-2295
Practice Address - Country:US
Practice Address - Phone:803-830-0541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11028487363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily