Healthcare Provider Details

I. General information

NPI: 1417448069
Provider Name (Legal Business Name): ONYE OMA BAHATI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1813 E ALTA VISTA RD
PHOENIX AZ
85042-4579
US

IV. Provider business mailing address

1813 E ALTA VISTA RD
PHOENIX AZ
85042-4579
US

V. Phone/Fax

Practice location:
  • Phone: 602-367-3006
  • Fax: 602-268-7453
Mailing address:
  • Phone: 602-367-3006
  • Fax: 602-268-7453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: