Healthcare Provider Details

I. General information

NPI: 1871891374
Provider Name (Legal Business Name): KAREN MARIE RUSSELL DTR, CHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 03/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2203 DESSECKER DR NE
DOVER OH
44622
US

IV. Provider business mailing address

2203 DESSECKER DR NE
DOVER OH
44622-6988
US

V. Phone/Fax

Practice location:
  • Phone: 330-340-8314
  • Fax:
Mailing address:
  • Phone: 330-340-8314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number717561
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: