Healthcare Provider Details

I. General information

NPI: 1306380548
Provider Name (Legal Business Name): AMY LANAE LARUSSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 LUNA ST SE
LOS LUNAS NM
87031-6814
US

IV. Provider business mailing address

4805 MARQUETTE AVE NE APT 107
ALBUQUERQUE NM
87108-1264
US

V. Phone/Fax

Practice location:
  • Phone: 205-913-4524
  • Fax:
Mailing address:
  • Phone: 205-913-4524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: