Healthcare Provider Details

I. General information

NPI: 1073428546
Provider Name (Legal Business Name): KRISTEN RUSSELL
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18548 KING WILLIAM RD
KING WILLIAM VA
23086-2909
US

IV. Provider business mailing address

5004 MONUMENT AVE STE 104
RICHMOND VA
23230-3629
US

V. Phone/Fax

Practice location:
  • Phone: 804-769-3434
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2204001835
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: