MEDICARE: MS. KAREN MARIE RUSSELL DTR, CHC

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	136A00000X	Registered Dietetic Technician	717561	OH

General Provider Information

NPI Number	:	1871891374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KAREN MARIE RUSSELL DTR, CHC

Provider Business Mailing Address
First Line	:	2203 DESSECKER DR NE
Second Line	:
City	:	DOVER
State	:	OH
Zip	:	44622-6988
Country	:	US
Telephone Number	:	330-340-8314
Fax Number	:

Provider Business Practice Location Address
First Line	:	2203 DESSECKER DR NE
Second Line	:
City	:	DOVER
State	:	OH
Zip	:	44622
Country	:	US
Telephone Number	:	330-340-8314
Fax Number	:

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

Provider Enumeration Date	:	03/08/2011
Last Update Date	:	03/08/2011

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