Healthcare Provider Details

I. General information

NPI: 1023884640
Provider Name (Legal Business Name): AMONAE DANYEL RUSSELL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 11/27/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 MISTWOOD CT
ORANGE PARK FL
32065-2295
US

IV. Provider business mailing address

425 MISTWOOD CT
ORANGE PARK FL
32065-2295
US

V. Phone/Fax

Practice location:
  • Phone: 803-830-0541
  • Fax:
Mailing address:
  • Phone: 803-830-0541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11028487
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: