Healthcare Provider Details

I. General information

NPI: 1356399125
Provider Name (Legal Business Name): KATHLEEN SUSAN DIAL R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN SUSAN JOHNSON R.D.

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 S 6TH AVE NUTRITION & FOOD SERVICE (5-120)
TUCSON AZ
85723-0001
US

IV. Provider business mailing address

7236 E SABINO VISTA DR
TUCSON AZ
85750-2217
US

V. Phone/Fax

Practice location:
  • Phone: 520-792-1450
  • Fax: 520-629-4691
Mailing address:
  • Phone: 520-792-1450
  • Fax: 520-629-4691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number368621
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: