Provider Demographics
NPI:1194132068
Name:RUSSELL, KRISTA GAIL (ARNP, FNP-C)
Entity type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:GAIL
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:ARNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23125 HILLSDALE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33954-2455
Mailing Address - Country:US
Mailing Address - Phone:941-457-9825
Mailing Address - Fax:
Practice Address - Street 1:19531 COCHRAN BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-2081
Practice Address - Country:US
Practice Address - Phone:941-235-3452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-12
Last Update Date:2014-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9269076363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily