Basic Information
| Provider Information | |||||||||
| NPI: | 1366403883 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OWEN | ||||||||
| FirstName: | CRISTIANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COSTA | ||||||||
| OtherFirstName: | CRISTIANA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1441 N 12TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024954577 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6644 E BAYWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852061747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809814388 | ||||||||
| FaxNumber: | 4809814198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 960792 | AZ | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.