Provider Demographics
NPI:1891921607
Name:RUSSELL, WANDA L
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:L
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N MORRISON BLVD
Mailing Address - Street 2:SUITE G
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-2312
Mailing Address - Country:US
Mailing Address - Phone:985-543-4113
Mailing Address - Fax:985-543-4109
Practice Address - Street 1:620 N MORRISON BLVD
Practice Address - Street 2:SUITE G
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-2312
Practice Address - Country:US
Practice Address - Phone:985-543-4113
Practice Address - Fax:985-543-4109
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA445133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered