Provider Demographics
NPI:1629555222
Name:DELLAVALLE, DIANE M. M (PHD, RDN, LDN)
Entity Type:Individual
Prefix:DR
First Name:DIANE M.
Middle Name:M
Last Name:DELLAVALLE
Suffix:
Gender:F
Credentials:PHD, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1133
Mailing Address - Street 2:
Mailing Address - City:GOULDSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:18424-1133
Mailing Address - Country:US
Mailing Address - Phone:607-229-3683
Mailing Address - Fax:
Practice Address - Street 1:88 MOUNTAINSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:GOULDSBORO
Practice Address - State:PA
Practice Address - Zip Code:18424-1133
Practice Address - Country:US
Practice Address - Phone:607-229-3683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN001084133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered