Provider Demographics
NPI:1538317375
Name:RUSSE, ALYSSA (LND)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:RUSSE
Suffix:
Gender:F
Credentials:LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1766
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:PR
Mailing Address - Zip Code:00677-1766
Mailing Address - Country:US
Mailing Address - Phone:787-515-2731
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA 115 BARRIO PUEBLO URB VILLA LA PRADERA
Practice Address - Street 2:CALLE GAVIOTAS # 51
Practice Address - City:RINCON
Practice Address - State:PR
Practice Address - Zip Code:00677-1766
Practice Address - Country:US
Practice Address - Phone:787-515-2731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1423133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist