Individual
PHYLLIS RUSSELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MS RD CDN
Contact information
Practice address
13519 242ND ST, ROSEDALE, NY 11422-1521
(917) 601-4575
Mailing address
13519 242ND ST, ROSEDALE, NY 11422-1521
(917) 601-4575
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
003127-01
NY
133VN1101X
Gerontological Nutrition Registered Dietitian
—
—
133VN1201X
Obesity and Weight Management Nutrition Registered Dietitian
—
—
Other
Enumeration date
10/26/2021
Last updated
10/26/2021
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