Provider Demographics
NPI:1245639194
Name:DAGROSA, DIANA (LAC)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:DAGROSA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8701 E VISTA BONITA DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-3207
Mailing Address - Country:US
Mailing Address - Phone:480-629-8110
Mailing Address - Fax:
Practice Address - Street 1:8701 E VISTA BONITA DR
Practice Address - Street 2:SUITE 110
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-3207
Practice Address - Country:US
Practice Address - Phone:480-629-8110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-16
Last Update Date:2014-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
AZ0422171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No133N00000XDietary & Nutritional Service ProvidersNutritionist