Provider Demographics
NPI:1477654903
Name:PHILLIPS, DIANE L (RD, LD, CDE)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 N BEAVER ST STE 201
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3126
Mailing Address - Country:US
Mailing Address - Phone:928-214-3920
Mailing Address - Fax:
Practice Address - Street 1:1215 N BEAVER ST STE 201
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3126
Practice Address - Country:US
Practice Address - Phone:928-214-3920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM417133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000G6686Medicaid
8HAU37Medicare ID - Type Unspecified
8HBE92Medicare ID - Type Unspecified
8HAU38Medicare ID - Type Unspecified
NM000G6686Medicaid
8HAU40Medicare ID - Type Unspecified
8HAU39Medicare ID - Type Unspecified