Provider Demographics
NPI:1760814057
Name:RUSSELL, MICHELLE LYNN (RD, LD)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:KUSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:2055 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601-4449
Mailing Address - Country:US
Mailing Address - Phone:319-759-6424
Mailing Address - Fax:
Practice Address - Street 1:320 N 3RD ST STE 416
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-5308
Practice Address - Country:US
Practice Address - Phone:319-208-9038
Practice Address - Fax:855-856-5956
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002008133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered