Provider Demographics
NPI:1831245687
Name:RUSSO, LISA MARIA (RD)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIA
Last Name:RUSSO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:MARIA
Other - Last Name:BAPTISTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:10 CHURCH TOWERS
Mailing Address - Street 2:APT 2N
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030
Mailing Address - Country:US
Mailing Address - Phone:973-460-0616
Mailing Address - Fax:
Practice Address - Street 1:216 PALMER ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-5900
Practice Address - Country:US
Practice Address - Phone:908-353-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ952153133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0251854103OtherUNITED HEALTH CARE
NJ11452348OtherCOUNCIL OF AFFORDABLE QUA
NJ223452311OtherHORIZON BLUE CROSS
NJ3980567OtherAETNA US HEALTHCARE
NJP3595969OtherOXFORD
NJ223452311OtherGREAT WEST
NJ11452348OtherCOUNCIL OF AFFORDABLE QUA