Provider Demographics
NPI:1649564352
Name:RUSSO, CARRIE ELIZABETH (NTP)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:ELIZABETH
Last Name:RUSSO
Suffix:
Gender:F
Credentials:NTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 SW MEADOW DR
Mailing Address - Street 2:SUITE 121
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-7130
Mailing Address - Country:US
Mailing Address - Phone:971-563-5300
Mailing Address - Fax:
Practice Address - Street 1:650 SW MEADOW DR
Practice Address - Street 2:SUITE 121
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-7130
Practice Address - Country:US
Practice Address - Phone:971-563-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR001012133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist