MEDICARE: MS. MICHELLE LYNN RUSSELL RD, 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	002008	IA

General Provider Information

NPI Number	:	1760814057
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MICHELLE LYNN RUSSELL RD, LD

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

Provider Business Practice Location Address
First Line	:	320 N 3RD ST STE 416
Second Line	:
City	:	BURLINGTON
State	:	IA
Zip	:	52601-5308
Country	:	US
Telephone Number	:	319-208-9038
Fax Number	:	855-856-5956

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

Provider Enumeration Date	:	08/08/2013
Last Update Date	:	07/22/2021

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