Provider Demographics
NPI:1912560079
Name:SELVAGGI, DIANE (RDN CDE MHS)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:SELVAGGI
Suffix:
Gender:F
Credentials:RDN CDE MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 WOODSTOCK AVE
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-4212
Mailing Address - Country:US
Mailing Address - Phone:203-675-5388
Mailing Address - Fax:
Practice Address - Street 1:40 COMMERCE PARK STE 1
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3535
Practice Address - Country:US
Practice Address - Phone:203-878-3531
Practice Address - Fax:866-284-6188
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT526452133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty