Provider Demographics
NPI:1972868305
Name:RUSSO, KRISTEN M (TVI)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:M
Last Name:RUSSO
Suffix:
Gender:F
Credentials:TVI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 SAYVILLE BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782
Mailing Address - Country:US
Mailing Address - Phone:631-589-2336
Mailing Address - Fax:
Practice Address - Street 1:272 SAYVILLE BOULEVARD
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782
Practice Address - Country:US
Practice Address - Phone:631-589-2336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist