Provider Demographics
NPI:1639159668
Name:HENDERIKS, DIANE M (RD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:HENDERIKS
Suffix:
Gender:F
Credentials:RD
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 486
Mailing Address - Street 2:
Mailing Address - City:OAKHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07755-0486
Mailing Address - Country:US
Mailing Address - Phone:732-922-6269
Mailing Address - Fax:732-918-8757
Practice Address - Street 1:4 HARTFORD DR
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07701-4929
Practice Address - Country:US
Practice Address - Phone:732-922-6269
Practice Address - Fax:732-918-8757
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ857625133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered