Provider Demographics
NPI:1578171757
Name:RUSSELL, KRYSTLE DANIELLE (APRN)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:DANIELLE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9912 HAROLD BEDFORD RD
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-7659
Mailing Address - Country:US
Mailing Address - Phone:813-610-2273
Mailing Address - Fax:
Practice Address - Street 1:9912 HAROLD BEDFORD RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-7659
Practice Address - Country:US
Practice Address - Phone:813-690-0765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11008108363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner