Provider Demographics
NPI:1174407704
Name:RUSSO, AMY L (HIS)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:RUSSO
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 MAY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-5115
Mailing Address - Country:US
Mailing Address - Phone:908-759-8062
Mailing Address - Fax:
Practice Address - Street 1:495 WATCHUNG AVE
Practice Address - Street 2:
Practice Address - City:WATCHUNG
Practice Address - State:NJ
Practice Address - Zip Code:07069-4945
Practice Address - Country:US
Practice Address - Phone:908-561-1247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MG00157600237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist