Healthcare Provider Details

I. General information

NPI: 1730678400
Provider Name (Legal Business Name): AZ DIETITIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6124 E BROWN RD STE 102
MESA AZ
85205-4959
US

IV. Provider business mailing address

6124 E BROWN RD STE 102
MESA AZ
85205-4959
US

V. Phone/Fax

Practice location:
  • Phone: 480-809-6513
  • Fax:
Mailing address:
  • Phone: 480-809-6513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86063644
License Number StateAZ

VIII. Authorized Official

Name: WENDY MARIE GREEN
Title or Position: OWNER
Credential:
Phone: 480-809-6513