Provider Demographics
NPI:1891206348
Name:WAY, SHEILA R (RD)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:R
Last Name:WAY
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 1:16620 N 40TH ST STE G1
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3351
Mailing Address - Country:US
Mailing Address - Phone:623-570-0095
Mailing Address - Fax:480-247-4179
Practice Address - Street 1:14045 N 7TH ST STE 4
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-4387
Practice Address - Country:US
Practice Address - Phone:623-399-6825
Practice Address - Fax:623-505-3474
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86076165133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPENDINGMedicaid