Provider Demographics
NPI:1750503900
Name:SELLECK, DIANE MARIE (RD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:SELLECK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:SELLECK
Other - Last Name:HAYWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:122 SUNFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6658
Mailing Address - Country:US
Mailing Address - Phone:928-855-5289
Mailing Address - Fax:
Practice Address - Street 1:12033 AGENCY RD
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-7718
Practice Address - Country:US
Practice Address - Phone:928-669-3283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
932530133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
932530OtherCDR REGISTRATION ID NUMBE
IN37001488AOtherDIETITIAN CERTIFICATION