Provider Demographics
NPI:1952922288
Name:INSALACO, DIANE C
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:C
Last Name:INSALACO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5810
Mailing Address - Country:US
Mailing Address - Phone:570-371-3572
Mailing Address - Fax:
Practice Address - Street 1:500 3RD AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5810
Practice Address - Country:US
Practice Address - Phone:570-371-3572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA86075586133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered