Healthcare Provider Details

I. General information

NPI: 1942772728
Provider Name (Legal Business Name): MYA TUESDAY PERKINS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MYA TUESDAY JOHNSON RD

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 N HIGLEY RD STE 306
GILBERT AZ
85234-1625
US

IV. Provider business mailing address

410 E 9TH AVE APT 10
MESA AZ
85204-4141
US

V. Phone/Fax

Practice location:
  • Phone: 480-543-2606
  • Fax:
Mailing address:
  • Phone: 602-733-7509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: