Provider Demographics
NPI:1952517286
Name:CROWLEY, PHYLLIS STELL (MS, RD, IBCLC)
Entity type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:STELL
Last Name:CROWLEY
Suffix:
Gender:F
Credentials:MS, RD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7907 HONEYWOOD COVE DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-5916
Mailing Address - Country:US
Mailing Address - Phone:801-944-0956
Mailing Address - Fax:
Practice Address - Street 1:7907 HONEYWOOD COVE DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-5916
Practice Address - Country:US
Practice Address - Phone:801-944-0956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT375264-4901133V00000X
TN0000000124133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered