Provider Demographics
NPI:1467657767
Name:RUSSO, SANDRA GERALDINE (RD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:GERALDINE
Last Name:RUSSO
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 1:2925 PALO VERDE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-1552
Mailing Address - Country:US
Mailing Address - Phone:562-429-2473
Mailing Address - Fax:
Practice Address - Street 1:2925 PALO VERDE AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-1552
Practice Address - Country:US
Practice Address - Phone:562-429-2473
Practice Address - Fax:562-496-5577
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA838417133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8381417OtherCDR