Provider Demographics
NPI:1821210691
Name:DOUGLASS, DIANE JUNE (CDN, DTR)
Entity Type:Individual
Prefix:MISS
First Name:DIANE
Middle Name:JUNE
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:CDN, DTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SHAPER AVE
Mailing Address - Street 2:
Mailing Address - City:CANAJOHARIE
Mailing Address - State:NY
Mailing Address - Zip Code:13317-1326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:178 GRANDVIEW DR
Practice Address - Street 2:BASSETT HOSPITAL OF SCHOHARIE COUNTY
Practice Address - City:COBLESKILL
Practice Address - State:NY
Practice Address - Zip Code:12043-5144
Practice Address - Country:US
Practice Address - Phone:518-254-3403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004410133N00000X
NY708965136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133N00000XDietary & Nutritional Service ProvidersNutritionist
Not Answered136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered