Healthcare Provider Details

I. General information

NPI: 1942670948
Provider Name (Legal Business Name): DIANA WALLEY MNT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2015
Last Update Date: 10/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 JACKSON CIR
LOUISVILLE CO
80027-1629
US

IV. Provider business mailing address

122 JACKSON CIR
LOUISVILLE CO
80027-1629
US

V. Phone/Fax

Practice location:
  • Phone: 401-835-5687
  • Fax:
Mailing address:
  • Phone: 401-835-5687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: