Healthcare Provider Details

I. General information

NPI: 1790255024
Provider Name (Legal Business Name): DIANE GARDNER RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10750 W MCDOWELL RD STE A300
AVONDALE AZ
85392-5963
US

IV. Provider business mailing address

18001 N 79TH AVE STE A12
GLENDALE AZ
85308-8398
US

V. Phone/Fax

Practice location:
  • Phone: 623-399-6825
  • Fax: 623-505-3474
Mailing address:
  • Phone: 623-399-6825
  • Fax: 623-505-3474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number714267
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: