Provider Demographics
NPI:1689608523
Name:RUSSELL, LAURA CHRISTINE (RD, CDE)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:CHRISTINE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:CHRISTINE
Other - Last Name:BUKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CDE
Mailing Address - Street 1:7701 YORK AVE S STE 189
Mailing Address - Street 2:ENDOCRINOLOGY CLINIC OF MINNEAPOLIS
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5238
Mailing Address - Country:US
Mailing Address - Phone:952-915-4156
Mailing Address - Fax:952-927-6309
Practice Address - Street 1:7701 YORK AVE S STE 189
Practice Address - Street 2:ENDOCRINOLOGY CLINIC OF MINNEAPOLIS
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5238
Practice Address - Country:US
Practice Address - Phone:952-915-4156
Practice Address - Fax:952-927-6309
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
ND763133V00000X
MN3055133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000298908OtherBCBS PIN
MT0280823Medicaid