Provider Demographics
NPI:1407932585
Name:RODENBERG, DIANA LYNNE (RD, CDE)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNNE
Last Name:RODENBERG
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 N PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MO
Mailing Address - Zip Code:64119-1530
Mailing Address - Country:US
Mailing Address - Phone:816-842-4440
Mailing Address - Fax:816-298-7904
Practice Address - Street 1:6420 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64119-1530
Practice Address - Country:US
Practice Address - Phone:816-842-4440
Practice Address - Fax:816-298-7904
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001025077133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF06C174BMedicare ID - Type UnspecifiedPROVIDER NUMBER