Provider Demographics
NPI:1154884658
Name:SULTANA, MST
Entity type:Individual
Prefix:
First Name:MST
Middle Name:
Last Name:SULTANA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2922 E EBONY DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-0012
Mailing Address - Country:US
Mailing Address - Phone:347-475-2672
Mailing Address - Fax:
Practice Address - Street 1:600 E BASELINE RD STE B-2
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1266
Practice Address - Country:US
Practice Address - Phone:602-770-7611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1091872133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered