Provider Demographics
NPI:1205325321
Name:RUSSELL, KRISTEN
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TILTONSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43963-1065
Mailing Address - Country:US
Mailing Address - Phone:304-231-4901
Mailing Address - Fax:
Practice Address - Street 1:163 STORMONT ST
Practice Address - Street 2:
Practice Address - City:NEW CONCORD
Practice Address - State:OH
Practice Address - Zip Code:43762-1118
Practice Address - Country:US
Practice Address - Phone:740-826-8211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer