Basic Information
| Provider Information | |||||||||
| NPI: | 1124497011 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASSUM | ||||||||
| FirstName: | KIRSTEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLAWSON | ||||||||
| OtherFirstName: | KIRSTEN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2702 N 3RD ST | ||||||||
| Address2: | SUITE 4020 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850041130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023233393 | ||||||||
| FaxNumber: | 6023233399 | ||||||||
| Practice Location | |||||||||
| Address1: | 1492 S MILL AVE | ||||||||
| Address2: | SUITE 312 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852815652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022437277 | ||||||||
| FaxNumber: | 4809271092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2015 | ||||||||
| LastUpdateDate: | 04/04/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 86012086 | AZ | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.