Healthcare Provider Details

I. General information

NPI: 1831245687
Provider Name (Legal Business Name): LISA MARIA RUSSO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA MARIA BAPTISTA RD

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 PALMER ST
ELIZABETH NJ
07202-5900
US

IV. Provider business mailing address

10 CHURCH TOWERS APT 2N
HOBOKEN NJ
07030
US

V. Phone/Fax

Practice location:
  • Phone: 908-353-0500
  • Fax:
Mailing address:
  • Phone: 973-460-0616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number952153
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: