Provider Demographics
NPI:1760720726
Name:FEDORISIN, DIANA M (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:M
Last Name:FEDORISIN
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 1:1677 HEMLOCK FARMS
Mailing Address - Street 2:
Mailing Address - City:LORDS VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:18428-9069
Mailing Address - Country:US
Mailing Address - Phone:570-257-0136
Mailing Address - Fax:
Practice Address - Street 1:1677 HEMLOCK FARMS
Practice Address - Street 2:
Practice Address - City:LORDS VALLEY
Practice Address - State:PA
Practice Address - Zip Code:18428-9069
Practice Address - Country:US
Practice Address - Phone:570-257-0136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-27
Last Update Date:2013-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004617133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered