Provider Demographics
NPI:1023772100
Name:RUSSELL, PHYLLIS (MS RD CDN)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MS RD CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13519 242ND ST
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-1521
Mailing Address - Country:US
Mailing Address - Phone:917-601-4575
Mailing Address - Fax:
Practice Address - Street 1:13519 242ND ST
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-1521
Practice Address - Country:US
Practice Address - Phone:917-601-4575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133VN1101X, 133VN1201X
NY003127-01133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1101XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Gerontological
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management