Provider Demographics
NPI:1114258357
Name:BLACK, DIANE ELAINE (MS,RD,CDE)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:ELAINE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MS,RD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10102 EDGECOMBE PL NE
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-4334
Mailing Address - Country:US
Mailing Address - Phone:412-400-3204
Mailing Address - Fax:
Practice Address - Street 1:2157 APPERSON DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7235
Practice Address - Country:US
Practice Address - Phone:540-777-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA572543133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered