Healthcare Provider Details

I. General information

NPI: 1316619901
Provider Name (Legal Business Name): AMY GAUCK RUSSO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 KENMOOR AVE SE STE 200
GRAND RAPIDS MI
49546-8622
US

IV. Provider business mailing address

655 KENMOOR AVE SE STE 200
GRAND RAPIDS MI
49546-8622
US

V. Phone/Fax

Practice location:
  • Phone: 616-363-7690
  • Fax: 616-942-8917
Mailing address:
  • Phone: 616-363-7690
  • Fax: 616-942-8917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1052618
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704302008
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: