Provider Demographics
NPI:1750770244
Name:RUSSELL, KRYSTAL (CNP)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636643
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6643
Mailing Address - Country:US
Mailing Address - Phone:440-989-3801
Mailing Address - Fax:440-960-0264
Practice Address - Street 1:1607 STATE RD
Practice Address - Street 2:STE 6
Practice Address - City:VERMILION
Practice Address - State:OH
Practice Address - Zip Code:44089-9142
Practice Address - Country:US
Practice Address - Phone:440-967-8713
Practice Address - Fax:440-967-1938
Is Sole Proprietor?:No
Enumeration Date:2015-01-21
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA16948363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0119107Medicaid
OH3025372Medicaid
H443230Medicare PIN
OH9376891Medicare PIN
OHH443232Medicare PIN
OH9389631Medicare PIN
H443231Medicare PIN