Basic Information
Provider Information | |||||||||
NPI: | 1154886349 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOURNEY | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, RD, CNSC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4728 N 9TH ST | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850143610 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4694179811 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1919 E THOMAS RD | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850167710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029330920 | ||||||||
FaxNumber: | 6029332492 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/01/2019 | ||||||||
LastUpdateDate: | 12/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X |   |   | N |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   | 133VN1004X |   |   | N |   | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric | 133VN1004X | 86048568 | AZ | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric |
No ID Information.