Provider Demographics
NPI:1811064025
Name:VICK, DIANNE CAMERON (RD)
Entity type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:CAMERON
Last Name:VICK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:21187 INDIAN TOWN RD
Mailing Address - Street 2:
Mailing Address - City:COURTLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23837-2449
Mailing Address - Country:US
Mailing Address - Phone:757-653-0127
Mailing Address - Fax:757-569-6452
Practice Address - Street 1:100 FAIRVIEW DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851-1238
Practice Address - Country:US
Practice Address - Phone:757-569-6138
Practice Address - Fax:757-569-6452
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA721778133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA003572F96Medicare UPIN