Healthcare Provider Details

I. General information

NPI: 1538000492
Provider Name (Legal Business Name): KRISTIN RUSSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2026
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 NATURE WALK PKWY STE 108101
ST AUGUSTINE FL
32092-5073
US

IV. Provider business mailing address

6767 ARCHING BRANCH CIR
JACKSONVILLE FL
32258-8449
US

V. Phone/Fax

Practice location:
  • Phone: 904-328-7489
  • Fax: 904-490-8549
Mailing address:
  • Phone: 904-504-5209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA16212
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: