MEDICARE: STEPHANIE ALICE RUSSELL RDN, LD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	987692	WA
2	133V00000X	Registered Dietitian	LD-D-10255383	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	987692	OTHER	WA	CDR
2	DI00002073	OTHER	WA	DOH/CD

General Provider Information

NPI Number	:	1093983959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE ALICE RUSSELL RDN, LD

Provider Business Mailing Address
First Line	:	369 NE REVERE AVE STE 105
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97701-4082
Country	:	US
Telephone Number	:	541-323-3488
Fax Number	:	541-323-3483

Provider Business Practice Location Address
First Line	:	369 NE REVERE AVE STE 105
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97701-4082
Country	:	US
Telephone Number	:	541-323-3488
Fax Number	:	541-323-3483

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2008
Last Update Date	:	11/26/2025

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