Provider Demographics
NPI:1437230133
Name:RUSSELL, HEATHER (RD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:GLADISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:202 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3511
Mailing Address - Country:US
Mailing Address - Phone:973-945-4029
Mailing Address - Fax:
Practice Address - Street 1:703 MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2621
Practice Address - Country:US
Practice Address - Phone:973-754-2526
Practice Address - Fax:973-754-3792
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ918318133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
7654551OtherAETNA
P3664391OtherOXFORD HEALTH PLANS
P3664398OtherOXFORD HEALTH PLANS
2612526OtherUNITEDHEALTHCARE