Provider Demographics
NPI:1851692123
Name:RUSK, LAUREN ASHLEY (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ASHLEY
Last Name:RUSK
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61636-4310
Mailing Address - Country:US
Mailing Address - Phone:309-672-4240
Mailing Address - Fax:
Practice Address - Street 1:9900 N DALEA LN
Practice Address - Street 2:9212
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-7268
Practice Address - Country:US
Practice Address - Phone:309-310-7259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005366133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered