Individual
AMY RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1100 W 6TH AVE, GARY, IN 46402-1711
(219) 885-4264
Mailing address
2730 NEW HAMPSHIRE ST, LAKE STATION, IN 46405-1346
(219) 671-6187
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
27056440A
IN
Other
Enumeration date
04/05/2019
Last updated
04/05/2019
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