Provider Demographics
NPI:1508151648
Name:LUSSIER, KRISTA LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTA
Middle Name:LYNN
Last Name:LUSSIER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KRISTA
Other - Middle Name:LYNN
Other - Last Name:PENTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:345 BLACKSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4800
Mailing Address - Country:US
Mailing Address - Phone:401-455-6375
Mailing Address - Fax:
Practice Address - Street 1:345 BLACKSTONE BLVD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4800
Practice Address - Country:US
Practice Address - Phone:401-455-6375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP022402084P0800X
RIMD146562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry