Healthcare Provider Details

I. General information

NPI: 1851883060
Provider Name (Legal Business Name): LINZY JAE PETERSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 06/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9305 W THOMAS RD STE 360
PHOENIX AZ
85037-3367
US

IV. Provider business mailing address

9305 W THOMAS RD STE 360
PHOENIX AZ
85037-3367
US

V. Phone/Fax

Practice location:
  • Phone: 623-327-8200
  • Fax:
Mailing address:
  • Phone: 623-327-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86084652
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: