Provider Demographics
NPI:1790090033
Name:DADIVAS, DIANE MARTINEZ (RD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARTINEZ
Last Name:DADIVAS
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 1:8439 N CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-1803
Mailing Address - Country:US
Mailing Address - Phone:281-901-8481
Mailing Address - Fax:833-271-4447
Practice Address - Street 1:8439 N CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-1803
Practice Address - Country:US
Practice Address - Phone:281-901-8481
Practice Address - Fax:833-271-4447
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-11
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005298133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric