Provider Demographics
NPI:1386890051
Name:RUSNAK, ROMAINE T (RD)
Entity type:Individual
Prefix:
First Name:ROMAINE
Middle Name:T
Last Name:RUSNAK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 W 120TH ST
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1211
Mailing Address - Country:US
Mailing Address - Phone:708-671-0179
Mailing Address - Fax:708-671-1730
Practice Address - Street 1:8614 W 120TH ST
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-1211
Practice Address - Country:US
Practice Address - Phone:708-671-0179
Practice Address - Fax:708-671-1730
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164001849133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered