Provider Demographics
NPI:1518442862
Name:RUSSELL, HOLLY ANN (RD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANN
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 1:15464 GALAXIE AVE APT 136
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-3163
Mailing Address - Country:US
Mailing Address - Phone:651-587-0566
Mailing Address - Fax:
Practice Address - Street 1:500 HARVARD ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0363
Practice Address - Country:US
Practice Address - Phone:612-273-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN86027517133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered