Healthcare Provider Details

I. General information

NPI: 1881045375
Provider Name (Legal Business Name): TRISTINE BOGLE R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2016
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4838 E BASELINE RD STE 122
MESA AZ
85206-4675
US

IV. Provider business mailing address

3564 E MESQUITE ST
GILBERT AZ
85296-1830
US

V. Phone/Fax

Practice location:
  • Phone: 602-694-4011
  • Fax: 833-561-1964
Mailing address:
  • Phone: 602-622-0142
  • Fax: 833-561-1964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: