Provider Demographics
NPI:1063076081
Name:RUSSOW, KRYSTLE (RRT)
Entity type:Individual
Prefix:MRS
First Name:KRYSTLE
Middle Name:
Last Name:RUSSOW
Suffix:
Gender:F
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7413 RED BIRD DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-9454
Mailing Address - Country:US
Mailing Address - Phone:313-671-9555
Mailing Address - Fax:
Practice Address - Street 1:4646 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1916
Practice Address - Country:US
Practice Address - Phone:313-671-9555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI44010066192279P3800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279P3800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredPalliative/Hospice