Provider Demographics
NPI:1073876744
Name:DIAQUE BALLESTEROS, PAULA (RD)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:DIAQUE BALLESTEROS
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:ONE JOSLIN PLACE
Mailing Address - Street 2:204 LATINO
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5306
Mailing Address - Country:US
Mailing Address - Phone:617-309-2400
Mailing Address - Fax:617-309-2457
Practice Address - Street 1:ONE JOSLIN PLACE
Practice Address - Street 2:204 LATINO
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5306
Practice Address - Country:US
Practice Address - Phone:617-309-2400
Practice Address - Fax:617-309-2457
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3318133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
133V00000XMedicare Oscar/Certification