Provider Demographics
NPI:1629177266
Name:CULLUM-DUGAN, DIANA (RD LDN)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:CULLUM-DUGAN
Suffix:
Gender:F
Credentials:RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-1822
Mailing Address - Country:US
Mailing Address - Phone:617-678-0607
Mailing Address - Fax:617-393-4455
Practice Address - Street 1:188 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-1822
Practice Address - Country:US
Practice Address - Phone:617-678-0607
Practice Address - Fax:617-393-4455
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1630133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1630OtherMA LICENSE
MA1630OtherMA LICENSE