Provider Demographics
NPI:1316619901
Name:RUSSO, AMY GAUCK (FNP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:GAUCK
Last Name:RUSSO
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:655 KENMOOR AVE SE STE 200
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8622
Mailing Address - Country:US
Mailing Address - Phone:616-363-7690
Mailing Address - Fax:616-942-8917
Practice Address - Street 1:1301 W 38TH ST STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1010
Practice Address - Country:US
Practice Address - Phone:512-477-5905
Practice Address - Fax:512-687-1490
Is Sole Proprietor?:No
Enumeration Date:2021-10-01
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704302008363LF0000X
TX1052618363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily