Provider Demographics
NPI:1750311049
Name:ROSA, DIANA E (MS, RD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:E
Last Name:ROSA
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1178 MOOSE HILL RD
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2394
Mailing Address - Country:US
Mailing Address - Phone:203-606-4949
Mailing Address - Fax:410-861-6262
Practice Address - Street 1:330 ORCHARD ST
Practice Address - Street 2:SUITE 307
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4417
Practice Address - Country:US
Practice Address - Phone:203-606-4949
Practice Address - Fax:410-861-6262
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT852206133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT270000453CT01OtherANTHEM BCBS
CT270000453CT01OtherANTHEM BCBS