Healthcare Provider Details

I. General information

NPI: 1407212095
Provider Name (Legal Business Name): CHRISTY KULLMAN RUSSELL N.P.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2016
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8988 FERN PARK DR
BURKE VA
22015-1635
US

IV. Provider business mailing address

28 14TH ST NE
WASHINGTON DC
20002-8437
US

V. Phone/Fax

Practice location:
  • Phone: 703-978-6061
  • Fax:
Mailing address:
  • Phone: 571-294-9655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024173139
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: