Provider Demographics
NPI:1801551098
Name:RUSS, AMANDA KATHLEEN (DNP, APRN)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:KATHLEEN
Last Name:RUSS
Suffix:
Gender:F
Credentials:DNP, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 AITKIN LOOP
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-2955
Mailing Address - Country:US
Mailing Address - Phone:435-590-3818
Mailing Address - Fax:
Practice Address - Street 1:1400 N US HIGHWAY 441 STE 942
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32159-6813
Practice Address - Country:US
Practice Address - Phone:352-751-4958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11014385363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics