Provider Demographics
NPI:1346776184
Name:RUSSELL, TAYLA
Entity Type:Individual
Prefix:
First Name:TAYLA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6556 S BIG COTTONWOOD CYN
Mailing Address - Street 2:SUITE #300
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-3580
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:185 W 600 N
Practice Address - Street 2:
Practice Address - City:MANTUA
Practice Address - State:UT
Practice Address - Zip Code:84324-4398
Practice Address - Country:US
Practice Address - Phone:435-553-5698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered