Provider Demographics
NPI:1487198222
Name:CHAN, ABBY ROSE (RDN)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:ROSE
Last Name:CHAN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-214-2800
Mailing Address - Fax:928-214-2932
Practice Address - Street 1:1200 N BEAVER ST
Practice Address - Street 2:PAYER CREDENTIALING
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3118
Practice Address - Country:US
Practice Address - Phone:928-213-6235
Practice Address - Fax:928-213-6292
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86052458133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ235726Medicaid
AZ235726Medicaid
AZZ198589Medicare PIN