Provider Demographics
NPI:1750954202
Name:BOUWER, KRISTIN RUSSELL (DNP)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:RUSSELL
Last Name:BOUWER
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:BARBARA
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8130 LAKEWOOD MAIN ST STE 103
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-5068
Mailing Address - Country:US
Mailing Address - Phone:941-499-2700
Mailing Address - Fax:941-487-0474
Practice Address - Street 1:8130 LAKEWOOD MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202-5068
Practice Address - Country:US
Practice Address - Phone:941-499-2700
Practice Address - Fax:941-487-0474
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11013948363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily