Provider Demographics
NPI:1457963365
Name:RUSSO, KRISTEN YAEGER (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:YAEGER
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:ANN
Other - Last Name:YAEGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, APRN, FNP-C
Mailing Address - Street 1:116 EAST AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-2300
Mailing Address - Country:US
Mailing Address - Phone:330-633-7782
Mailing Address - Fax:
Practice Address - Street 1:116 EAST AVE STE 3
Practice Address - Street 2:
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-2300
Practice Address - Country:US
Practice Address - Phone:330-633-7782
Practice Address - Fax:330-633-4701
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0026780363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0416557Medicaid