Provider Demographics
NPI:1194045781
Name:PANTALOS, DIANA C (RD)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:C
Last Name:PANTALOS
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 1:571 S FLOYD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3828
Mailing Address - Country:US
Mailing Address - Phone:502-852-7897
Mailing Address - Fax:502-852-2911
Practice Address - Street 1:571 S FLOYD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3828
Practice Address - Country:US
Practice Address - Phone:502-852-7897
Practice Address - Fax:502-852-2911
Is Sole Proprietor?:No
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1484133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1484OtherSTATE LICENSE