Basic Information
| Provider Information | |||||||||
| NPI: | 1851692123 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSK | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | ASHLEY | ||||||||
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| Credential: | MS, RD, LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 NE GLEN OAK AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616364310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096724240 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9900 N DALEA LN | ||||||||
| Address2: | 9212 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616157268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093107259 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2010 | ||||||||
| LastUpdateDate: | 11/03/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 164005366 | IL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.