Provider Demographics
NPI:1093420325
Name:KOPELAKIS, DIANE (RD LD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:KOPELAKIS
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7825 NAUTIQUE CT
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-7791
Mailing Address - Country:US
Mailing Address - Phone:561-436-6617
Mailing Address - Fax:
Practice Address - Street 1:7825 NAUTIQUE CT
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-7791
Practice Address - Country:US
Practice Address - Phone:561-436-6617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND3420133V00000X, 133VN1006X, 133VN1101X, 133VN1201X, 133VN1501X, 133N00000X, 133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133VN1101XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Gerontological
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
No133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports Dietetics
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
21000164980OtherUSED LLC DOC # BC HAVE NO OTHER #