Provider Demographics
NPI:1972177863
Name:RUSSELL, ALYSSA LYNNE (RDN, LD)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:LYNNE
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 1:10 LINDY LN
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-6338
Mailing Address - Country:US
Mailing Address - Phone:516-816-1086
Mailing Address - Fax:
Practice Address - Street 1:75 MARKET ST STE 304
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-5040
Practice Address - Country:US
Practice Address - Phone:207-400-6188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1393133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered