Healthcare Provider Details

I. General information

NPI: 1588385132
Provider Name (Legal Business Name): BRENDA LEE ROUNDTREE NDTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/12/2022
Certification Date: 09/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 E COUNTRY SHADOWS ST
GILBERT AZ
85298-9026
US

IV. Provider business mailing address

3103 E COUNTRY SHADOWS ST
GILBERT AZ
85298-9026
US

V. Phone/Fax

Practice location:
  • Phone: 602-853-6927
  • Fax:
Mailing address:
  • Phone: 602-853-6927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1085276
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number1085276
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number1085276
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: