Provider Demographics
NPI:1689439317
Name:RUSS, KYLE (CNS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:RUSS
Suffix:
Gender:M
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 GINGER TRL
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-2539
Mailing Address - Country:US
Mailing Address - Phone:847-971-9429
Mailing Address - Fax:
Practice Address - Street 1:640 GINGER TRL
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-2539
Practice Address - Country:US
Practice Address - Phone:847-971-9429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No171400000XOther Service ProvidersHealth & Wellness Coach