Provider Demographics
NPI:1124497011
Name:WASSUM, KIRSTEN
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:WASSUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:
Other - Last Name:CLAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2702 N 3RD ST
Mailing Address - Street 2:SUITE 4020
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1130
Mailing Address - Country:US
Mailing Address - Phone:602-323-3393
Mailing Address - Fax:602-323-3399
Practice Address - Street 1:1492 S MILL AVE
Practice Address - Street 2:SUITE 312
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-5652
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:480-927-1092
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86012086133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered