Provider Demographics
NPI:1205038619
Name:DAVIS, DIANA (RD, LDN)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD, LDN
Mailing Address - Street 1:452 ROYAL TERN DR
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-7175
Mailing Address - Country:US
Mailing Address - Phone:910-352-2165
Mailing Address - Fax:
Practice Address - Street 1:452 ROYAL TERN DR
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-7175
Practice Address - Country:US
Practice Address - Phone:910-352-2165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002639133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2994264Medicare ID - Type Unspecified