Basic Information
Provider Information | |||||||||
NPI: | 1760428767 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SPANIER | ||||||||
FirstName: | BETH | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5607 S 21ST PL | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850403456 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4806106111 | ||||||||
FaxNumber: | 4806106189 | ||||||||
Practice Location | |||||||||
Address1: | 2149 E WARNER RD | ||||||||
Address2: | SUITE 101 | ||||||||
City: | TEMPE | ||||||||
State: | AZ | ||||||||
PostalCode: | 852843494 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4806106111 | ||||||||
FaxNumber: | 4806106189 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1005X | 875189 | IL | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Renal |
ID Information
ID | Type | State | Issuer | Description | 875189 | 01 | IL | AMERICAN DIETETIC ASSOC | OTHER |