Provider Demographics
NPI:1396760435
Name:RUSSE, ANA M (LCDA)
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:M
Last Name:RUSSE
Suffix:
Gender:F
Credentials:LCDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 443
Mailing Address - Street 2:
Mailing Address - City:MOROVIS
Mailing Address - State:PR
Mailing Address - Zip Code:00687-0443
Mailing Address - Country:US
Mailing Address - Phone:787-862-5368
Mailing Address - Fax:787-862-5368
Practice Address - Street 1:URB. ATENAS MARGINAL ELLIOT VELEZ
Practice Address - Street 2:J-20
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-884-8923
Practice Address - Fax:787-884-8923
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR765133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist