MEDICARE: KELLY RUSSO

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	133VN1004X	Pediatric Nutrition Registered Dietitian	917553	NY

General Provider Information

NPI Number	:	1275495855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY RUSSO

Provider Business Mailing Address
First Line	:	783 MIDDLEBURY RD
Second Line	:
City	:	WEBSTER
State	:	NY
Zip	:	14580-2681
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 ELMWOOD AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14642-0001
Country	:	US
Telephone Number	:	585-275-2647
Fax Number	:

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

Provider Enumeration Date	:	12/02/2025
Last Update Date	:	12/02/2025

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Directions to “ KELLY RUSSO ” Practice Location

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