Healthcare Provider Details

I. General information

NPI: 1700551918
Provider Name (Legal Business Name): KIRSTIN JENNA RUSSELL PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIRSTIN J TIDQUIST

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 E 5TH ST STE 154A
WASHINGTON MO
63090-3135
US

IV. Provider business mailing address

851 E 5TH ST STE 154A
WASHINGTON MO
63090-3135
US

V. Phone/Fax

Practice location:
  • Phone: 636-266-7900
  • Fax: 636-266-7901
Mailing address:
  • Phone: 636-266-7900
  • Fax: 636-266-7901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71011436A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2025040266
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: