Provider Demographics
NPI:1669218566
Name:RUSSELL, DANIELLE VICTORIA (RD)
Entity type:Individual
Prefix:MS
First Name:DANIELLE
Middle Name:VICTORIA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 ROSEMOUNT CT
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2384
Mailing Address - Country:US
Mailing Address - Phone:321-266-5533
Mailing Address - Fax:
Practice Address - Street 1:107 ROSEMOUNT CT
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2384
Practice Address - Country:US
Practice Address - Phone:321-266-5533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA086046235133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered