Provider Demographics
NPI:1881160828
Name:ROSALES, KRISTYN-MAE RUSSO (APRN, FNP)
Entity type:Individual
Prefix:
First Name:KRISTYN-MAE
Middle Name:RUSSO
Last Name:ROSALES
Suffix:
Gender:F
Credentials:APRN, FNP
Other - Prefix:
Other - First Name:KRISTYN
Other - Middle Name:
Other - Last Name:RUSSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN, FNP
Mailing Address - Street 1:P O BOX 4439
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4439
Mailing Address - Country:US
Mailing Address - Phone:713-792-2991
Mailing Address - Fax:
Practice Address - Street 1:1515 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4009
Practice Address - Country:US
Practice Address - Phone:713-792-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136639363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX393519901Medicaid
TX393519902OtherMEDICAID-CSHCN
TX8KL761OtherBCBS