Provider Demographics
NPI:1558437756
Name:FAGAN, DIANNE M (RD)
Entity Type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:M
Last Name:FAGAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1184 ROSEHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:NISKAYUNA
Mailing Address - State:NY
Mailing Address - Zip Code:12309-4624
Mailing Address - Country:US
Mailing Address - Phone:518-382-0327
Mailing Address - Fax:518-381-9554
Practice Address - Street 1:2310 NOTT ST E
Practice Address - Street 2:SUITE 100
Practice Address - City:NISKAYUNA
Practice Address - State:NY
Practice Address - Zip Code:12309-4303
Practice Address - Country:US
Practice Address - Phone:518-526-0004
Practice Address - Fax:518-381-9554
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY968021OtherMVP HEALTHCARE