Healthcare Provider Details

I. General information

NPI: 1114258357
Provider Name (Legal Business Name): DIANE ELAINE BLACK MS,RD,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2010
Last Update Date: 01/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2157 APPERSON DR
SALEM VA
24153-7235
US

IV. Provider business mailing address

10102 EDGECOMBE PL NE
BAINBRIDGE ISLAND WA
98110-4334
US

V. Phone/Fax

Practice location:
  • Phone: 540-777-0000
  • Fax:
Mailing address:
  • Phone: 412-400-3204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number572543
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: