Provider Demographics
NPI:1497069645
Name:SPORTS, CHRISTINE E (RD)
Entity type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:E
Last Name:SPORTS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:E
Other - Last Name:WHEELER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:2108 E THOMAS RD STE 130
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-0008
Mailing Address - Country:US
Mailing Address - Phone:602-933-1813
Mailing Address - Fax:
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-933-0970
Practice Address - Fax:602-933-4253
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ990773133V00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ540320Medicaid
AZ0000OtherMEDICARE PENDING