Provider Demographics
NPI:1801511837
Name:RUSSO, KRISTIN THERESA (FNP)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:THERESA
Last Name:RUSSO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:THERESA
Other - Last Name:LESSLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:240 MEETING HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-5009
Mailing Address - Country:US
Mailing Address - Phone:631-726-8200
Mailing Address - Fax:
Practice Address - Street 1:240 MEETING HOUSE LN
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5009
Practice Address - Country:US
Practice Address - Phone:631-638-7702
Practice Address - Fax:631-638-7327
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY350492363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily