Provider Demographics
NPI:1629109178
Name:ADAY, SALLY A (RD)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:A
Last Name:ADAY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:AZ
Mailing Address - Zip Code:85550-0208
Mailing Address - Country:US
Mailing Address - Phone:928-475-2371
Mailing Address - Fax:928-475-7370
Practice Address - Street 1:223 CIBEQUE CIRCLE ROAD
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:AZ
Practice Address - Zip Code:85550-0208
Practice Address - Country:US
Practice Address - Phone:928-475-2371
Practice Address - Fax:928-475-7370
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
809443133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ169194Medicaid