Provider Demographics
NPI:1063862100
Name:RODGERS, DIANA (RD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:RODGERS
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 1:185 CONCORD ST
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:MA
Mailing Address - Zip Code:01741-1531
Mailing Address - Country:US
Mailing Address - Phone:978-998-9443
Mailing Address - Fax:
Practice Address - Street 1:185 CONCORD ST
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:MA
Practice Address - Zip Code:01741-1531
Practice Address - Country:US
Practice Address - Phone:978-998-9443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA00004122133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered