MEDICARE: MS. EMILY SUSAN CERVANTEZ RDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	86007532	AZ

General Provider Information

NPI Number	:	1659825610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. EMILY SUSAN CERVANTEZ RDN

Provider Business Mailing Address
First Line	:	4650 N CENTRAL AVE UNIT 317
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-1082
Country	:	US
Telephone Number	:	480-298-7159
Fax Number	:

Provider Business Practice Location Address
First Line	:	303 E BASELINE RD STE 107
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-6561
Country	:	US
Telephone Number	:	602-323-3342
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2016
Last Update Date	:	08/08/2016

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