Provider Demographics
NPI:1942670948
Name:WALLEY, DIANA (MNT)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:WALLEY
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 JACKSON CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-1629
Mailing Address - Country:US
Mailing Address - Phone:401-835-5687
Mailing Address - Fax:
Practice Address - Street 1:122 JACKSON CIR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-1629
Practice Address - Country:US
Practice Address - Phone:401-835-5687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist