Healthcare Provider Details

I. General information

NPI: 1922376193
Provider Name (Legal Business Name): ALEXA MARIE DIAZ RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 EAST BASELINE ROAD
PHOENIX AZ
85042-6551
US

IV. Provider business mailing address

2702 NORTH 3RD STREET 4020
PHOENIX AZ
85004-4608
US

V. Phone/Fax

Practice location:
  • Phone: 602-243-7277
  • Fax: 602-243-1235
Mailing address:
  • Phone: 602-323-3407
  • Fax: 602-323-3496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86002413
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: