Provider Demographics
NPI:1164849220
Name:CANN, DIANA (RD MPH)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:CANN
Suffix:
Gender:F
Credentials:RD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 CIDER ST
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-6558
Mailing Address - Country:US
Mailing Address - Phone:484-459-1481
Mailing Address - Fax:
Practice Address - Street 1:218 CIDER ST
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-6558
Practice Address - Country:US
Practice Address - Phone:484-459-1481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA914172133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist