Provider Demographics
NPI:1760191654
Name:RUSSELL, MAGNOLIA UMALI (RDN,LD)
Entity Type:Individual
Prefix:MRS
First Name:MAGNOLIA
Middle Name:UMALI
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RDN,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:597 LYTHAM DR
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-1183
Mailing Address - Country:US
Mailing Address - Phone:814-248-6768
Mailing Address - Fax:
Practice Address - Street 1:597 LYTHAM DR
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-1183
Practice Address - Country:US
Practice Address - Phone:814-248-6768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD005992133V00000X
SC2353133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered