Healthcare Provider Details

I. General information

NPI: 1598279523
Provider Name (Legal Business Name): ALLYSON ELAINE BOOTH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 N HIGLEY RD
GILBERT AZ
85234-1623
US

IV. Provider business mailing address

3464 E SIERRA MADRE AVE
GILBERT AZ
85296-1970
US

V. Phone/Fax

Practice location:
  • Phone: 480-543-2606
  • Fax:
Mailing address:
  • Phone: 480-223-7860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86002192
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: