Healthcare Provider Details

I. General information

NPI: 1558437756
Provider Name (Legal Business Name): DIANNE M FAGAN R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 NOTT ST E SUITE 100
NISKAYUNA NY
12309-4303
US

IV. Provider business mailing address

1184 ROSEHILL BLVD
NISKAYUNA NY
12309-4624
US

V. Phone/Fax

Practice location:
  • Phone: 518-526-0004
  • Fax: 518-381-9554
Mailing address:
  • Phone: 518-382-0327
  • Fax: 518-381-9554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: