Healthcare Provider Details

I. General information

NPI: 1558029330
Provider Name (Legal Business Name): DAISY CRUZ RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2021
Last Update Date: 05/26/2025
Certification Date: 05/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3421 N 7TH AVE
PHOENIX AZ
85013-3635
US

IV. Provider business mailing address

3421 N 7TH AVE
PHOENIX AZ
85013-3635
US

V. Phone/Fax

Practice location:
  • Phone: 800-881-5101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number86117917
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86117917
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: