Healthcare Provider Details

I. General information

NPI: 1265532394
Provider Name (Legal Business Name): KRISTEN J RUSSEK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN J WISE PT

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 COUNTY ROAD E E STE 120
VADNAIS HTS MN
55110-5191
US

IV. Provider business mailing address

1155 COUNTY ROAD E E STE 120
VADNAIS HTS MN
55110-5191
US

V. Phone/Fax

Practice location:
  • Phone: 651-241-1464
  • Fax:
Mailing address:
  • Phone: 651-241-1464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7688
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: