Provider Demographics
NPI:1477864197
Name:GUSTINES, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:GUSTINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12213 KAYSMOUNT CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-6936
Mailing Address - Country:US
Mailing Address - Phone:919-306-3447
Mailing Address - Fax:
Practice Address - Street 1:12213 KAYSMOUNT CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-6936
Practice Address - Country:US
Practice Address - Phone:919-306-3447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-28
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003214133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered