Provider Demographics
NPI:1043241839
Name:RUSSELL, MARY KRYSTOFIAK (RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KRYSTOFIAK
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5841 S MARYLAND AVE
Mailing Address - Street 2:MC 0988
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1447
Mailing Address - Country:US
Mailing Address - Phone:773-770-2150
Mailing Address - Fax:773-834-1011
Practice Address - Street 1:5841 S MARYLAND AVE
Practice Address - Street 2:MC 0988
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1447
Practice Address - Country:US
Practice Address - Phone:773-770-2150
Practice Address - Fax:773-834-1011
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered