Provider Demographics
NPI:1912234071
Name:RUSSELL, MARY MONICA (LRD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:MONICA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LRD, CDE
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:MONICA
Other - Last Name:BLAINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:LANDSTUHL REGIONAL MEDICAL CENTER
Mailing Address - Street 2:CMR 402
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180
Mailing Address - Country:US
Mailing Address - Phone:011491522-131-0207
Mailing Address - Fax:
Practice Address - Street 1:1702 EAST ROSE CREEK PARKWAY SOUTH
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-6834
Practice Address - Country:US
Practice Address - Phone:701-239-4946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND151133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered