Provider Demographics
NPI:1104297555
Name:RUSSELL, KATHRYN MARIE (MS, RDN)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2543 WOODMONT DR E
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188
Mailing Address - Country:US
Mailing Address - Phone:734-635-7771
Mailing Address - Fax:
Practice Address - Street 1:2543 WOODMONT DR E
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188
Practice Address - Country:US
Practice Address - Phone:734-635-7771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-12
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered