Provider Demographics
NPI:1467513929
Name:RUSSELL, TERI JO (RD)
Entity Type:Individual
Prefix:MRS
First Name:TERI
Middle Name:JO
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 1:5411 STARWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-3339
Mailing Address - Country:US
Mailing Address - Phone:940-696-8064
Mailing Address - Fax:
Practice Address - Street 1:5411 STARWOOD AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76310-3339
Practice Address - Country:US
Practice Address - Phone:940-696-8064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered