=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710435128
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEARSTIN K. RUSSELL APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2016
-----------------------------------------------------
Last Update Date | 12/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 W GORE ST STE 405
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806-1049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-841-9340
-----------------------------------------------------
Fax | 321-841-9344
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 W GORE ST STE 405
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806-1049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-841-9340
-----------------------------------------------------
Fax | 321-841-9344
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP131675
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 9309748
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | APRN9309748
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------