Healthcare Provider Details

I. General information

NPI: 1497587224
Provider Name (Legal Business Name): ANGELA KRISTIN RUSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11109 PARKVIEW PLAZA DR
FORT WAYNE IN
46845-1701
US

IV. Provider business mailing address

16313 ALLEN RD
HARLAN IN
46743-9727
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-2911
  • Fax:
Mailing address:
  • Phone: 260-750-9024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number28190806A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: