1760814057 NPI number — MS. MICHELLE LYNN RUSSELL RD, LD

Table of content: MS. MICHELLE LYNN RUSSELL RD, LD (NPI 1760814057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760814057 NPI number — MS. MICHELLE LYNN RUSSELL RD, LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
MICHELLE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RD, LD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KUSTER
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD, LD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760814057
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2055 HIGHLAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52601-4449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-759-6424
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 N 3RD ST STE 416
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52601-5308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-208-9038
Provider Business Practice Location Address Fax Number:
855-856-5956
Provider Enumeration Date:
08/08/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  002008 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)