Healthcare Provider Details

I. General information

NPI: 1023101136
Provider Name (Legal Business Name): LYNN E DIVEN RD LD CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 E PARK AVE STE 312
STATE COLLEGE PA
16803-6706
US

IV. Provider business mailing address

1850 E PARK AVE STE 312
STATE COLLEGE PA
16803-6706
US

V. Phone/Fax

Practice location:
  • Phone: 814-689-3156
  • Fax: 814-689-1954
Mailing address:
  • Phone: 814-689-3156
  • Fax: 814-689-1954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN003719
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: