Provider Demographics
NPI:1558609982
Name:BUSTAMANTE, DIANE I (RD CDN LDN)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:I
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:RD CDN LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11987 SOUTHERN BLVD
Mailing Address - Street 2:SUITE 1058
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411
Mailing Address - Country:US
Mailing Address - Phone:917-418-5710
Mailing Address - Fax:
Practice Address - Street 1:11987 SOUTHERN BLVD
Practice Address - Street 2:SUITE 1058
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411
Practice Address - Country:US
Practice Address - Phone:917-418-5710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-18
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY855630133V00000X
NY005542133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered