Provider Demographics
NPI:1831808385
Name:RUSSO, KATIE (RD, LD)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16624 LONELY PINES DR
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77302-8315
Mailing Address - Country:US
Mailing Address - Phone:281-728-4020
Mailing Address - Fax:
Practice Address - Street 1:18839 MCKAY DR
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-5721
Practice Address - Country:US
Practice Address - Phone:281-446-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT86206133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered