Healthcare Provider Details

I. General information

NPI: 1285692491
Provider Name (Legal Business Name): DIANE EHLE PIETROCARLO R.D., C.D.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 10/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 GLEASON RD PROFESSIONAL BUILDING
GLENVILLE NY
12302-5307
US

IV. Provider business mailing address

400 RECTOR RD
GLENVILLE NY
12302-6702
US

V. Phone/Fax

Practice location:
  • Phone: 518-384-0562
  • Fax: 518-384-0562
Mailing address:
  • Phone: 518-374-6424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number535353
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: