Provider Demographics
NPI:1295455681
Name:RUSSO, DOMINIQUE ASHLEY (RDN, LD)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:ASHLEY
Last Name:RUSSO
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 1:2412 JUNIPER CANYON CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-1836
Mailing Address - Country:US
Mailing Address - Phone:702-279-2523
Mailing Address - Fax:
Practice Address - Street 1:2850 W HORIZON RIDGE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4395
Practice Address - Country:US
Practice Address - Phone:702-485-7235
Practice Address - Fax:833-407-9212
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV39929-DI-0133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered