Provider Demographics
NPI:1619227097
Name:RUSSELL, MEGAN PAIGE (MED, RD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:PAIGE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MED, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 DILBECK LANE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240
Mailing Address - Country:US
Mailing Address - Phone:972-233-4444
Mailing Address - Fax:
Practice Address - Street 1:6060 DILBECK LANE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240
Practice Address - Country:US
Practice Address - Phone:972-233-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1016858133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
1016858OtherCOMMISION ON DIETETIC REGISTRATION