Healthcare Provider Details

I. General information

NPI: 1124886650
Provider Name (Legal Business Name): HEIDI PRINCE PHELPS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 03/11/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3916 E RAWHIDE ST
GILBERT AZ
85296-1826
US

IV. Provider business mailing address

3916 E RAWHIDE ST
GILBERT AZ
85296-1826
US

V. Phone/Fax

Practice location:
  • Phone: 480-415-3530
  • Fax:
Mailing address:
  • Phone: 480-415-3530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number5603
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: