Provider Demographics
NPI:1578747630
Name:PEDERSON, DIANA MARIE (RDCD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIE
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:RDCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1348
Practice Address - Country:US
Practice Address - Phone:608-287-2770
Practice Address - Fax:608-287-2777
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2067-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered