Provider Demographics
NPI:1497367189
Name:RUSSELL, KRISTINA DENIECE (CSFA)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:DENIECE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E ASH LN APT 1525
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-2431
Mailing Address - Country:US
Mailing Address - Phone:817-455-4919
Mailing Address - Fax:
Practice Address - Street 1:1901 N MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-2220
Practice Address - Country:US
Practice Address - Phone:972-579-8280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-23
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist