Provider Demographics
NPI:1295132207
Name:FELLOWS, ANASTACIA LEE (RD)
Entity type:Individual
Prefix:
First Name:ANASTACIA
Middle Name:LEE
Last Name:FELLOWS
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 1:15640 N 28TH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-4059
Mailing Address - Country:US
Mailing Address - Phone:602-439-9000
Mailing Address - Fax:
Practice Address - Street 1:15640 N 28TH DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-4059
Practice Address - Country:US
Practice Address - Phone:602-439-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86009160133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered