Provider Demographics
NPI:1316571920
Name:IMUS, KAREN MICHELE (RD)
Entity type:Individual
Prefix:MS
First Name:KAREN
Middle Name:MICHELE
Last Name:IMUS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3935 E ROUGH RIDER RD UNIT 1033
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-7348
Mailing Address - Country:US
Mailing Address - Phone:480-570-9766
Mailing Address - Fax:
Practice Address - Street 1:16620 N 40TH ST STE G1
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3351
Practice Address - Country:US
Practice Address - Phone:602-363-0629
Practice Address - Fax:480-247-4179
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ952489133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty