Provider Demographics
NPI:1285303172
Name:CLABOURNE, ALEXANDER (RDN)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:CLABOURNE
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 N DREAMY DRAW DR STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4668
Mailing Address - Country:US
Mailing Address - Phone:480-882-4545
Mailing Address - Fax:480-882-5814
Practice Address - Street 1:20440 N 27TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3240
Practice Address - Country:US
Practice Address - Phone:480-882-4545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
AZ86276869133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ122743Medicaid