Provider Demographics
NPI:1942748132
Name:FELICETTI, ERIN LEANN (RD)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:LEANN
Last Name:FELICETTI
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:
Other - Last Name:RUDIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 N. BEAVER
Mailing Address - Street 2:PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:1000 N HUMPHREYS ST
Practice Address - Street 2:SUITE 210
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3136
Practice Address - Country:US
Practice Address - Phone:928-214-3537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86067922133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ198721Medicare PIN