Provider Demographics
NPI:1497587224
Name:RUSS, ANGELA KRISTIN
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:KRISTIN
Last Name:RUSS
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 1:16313 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:IN
Mailing Address - Zip Code:46743-9727
Mailing Address - Country:US
Mailing Address - Phone:260-750-9024
Mailing Address - Fax:
Practice Address - Street 1:11109 PARKVIEW PLAZA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1701
Practice Address - Country:US
Practice Address - Phone:260-266-2911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28190806A364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist