Provider Demographics
NPI:1780441659
Name:RUSSELL, STEFANIE (RD, LDN)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12705 MOJAVE DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-4327
Mailing Address - Country:US
Mailing Address - Phone:732-861-3703
Mailing Address - Fax:
Practice Address - Street 1:12705 MOJAVE DR
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-4327
Practice Address - Country:US
Practice Address - Phone:732-861-3703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37003646A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered