Provider Demographics
NPI:1659825610
Name:CERVANTEZ, EMILY SUSAN (RDN)
Entity Type:Individual
Prefix:MS
First Name:EMILY
Middle Name:SUSAN
Last Name:CERVANTEZ
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 1:4650 N CENTRAL AVE UNIT 317
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1082
Mailing Address - Country:US
Mailing Address - Phone:480-298-7159
Mailing Address - Fax:
Practice Address - Street 1:303 E BASELINE RD STE 107
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6561
Practice Address - Country:US
Practice Address - Phone:602-323-3342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86007532133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered