Basic Information
| Provider Information | |||||||||
| NPI: | 1225449382 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MROZEK | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | |||||||||
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| Credential: | RDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6622 N 91ST AVE | ||||||||
| Address2: | STE 220 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853052569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027596883 | ||||||||
| FaxNumber: | 6022243358 | ||||||||
| Practice Location | |||||||||
| Address1: | 9100 N 2ND ST | ||||||||
| Address2: | SUITE 221, | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850202446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029431231 | ||||||||
| FaxNumber: | 6023959574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2014 | ||||||||
| LastUpdateDate: | 06/26/2018 | ||||||||
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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 | 723793 | AZ | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 86-0959487 | 01 | AZ | TAX ID | OTHER |