MEDICARE: KRISTIN RUSSO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SA16212	FL

General Provider Information

NPI Number	:	1538000492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN RUSSO

Provider Business Mailing Address
First Line	:	6767 ARCHING BRANCH CIR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-8449
Country	:	US
Telephone Number	:	904-504-5209
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 NATURE WALK PKWY STE 108101
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32092-5073
Country	:	US
Telephone Number	:	904-328-7489
Fax Number	:	904-490-8549

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2026
Last Update Date	:	04/03/2026

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Directions to “ KRISTIN RUSSO ” Practice Location

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