Provider Demographics
NPI:1073635108
Name:DIPUCCIO, TERA L (RD)
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:L
Last Name:DIPUCCIO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:TERA
Other - Middle Name:L
Other - Last Name:SUPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:3050 MACK RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5379
Mailing Address - Country:US
Mailing Address - Phone:513-557-7718
Mailing Address - Fax:
Practice Address - Street 1:3050 MACK RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5379
Practice Address - Country:US
Practice Address - Phone:513-557-7718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5876133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH390250Medicare PIN