Provider Demographics
NPI:1154979839
Name:RUSSO, AMBER NICOLE (APRN)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:NICOLE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:NICOLE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2201 51ST ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-3510
Mailing Address - Country:US
Mailing Address - Phone:727-421-4379
Mailing Address - Fax:
Practice Address - Street 1:2201 51ST ST N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-3510
Practice Address - Country:US
Practice Address - Phone:727-421-4379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002431363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner